THE 

DISEASES OF INFANCY 
AND CHILDHOOD 

FOR THE USE OF STUDENTS 
AND PRACTITIONERS OF MEDICINE 



BY 

L. EMMETT HOLT, A.M., M. D. 

PROFESSOR OF DISEASES OF CHILDREN IN THE NEW YORK POLYCLINIC J ATTENDING PHYSICIAN 

TO THE NURSERY AND CHILD'S AND THE BABIES' HOSPITALS, NEW YORK ; 

CONSULTING PHYSICIAN TO THE NEW YORK INFANT ASYLUM, AND 

TO THE HOSPITAL FOR THE RUPTURED AND CRIPPLED 



WITH TWO HUNDRED AND FOUR ILLUSTRATIONS 
INCLUDING SEVEN COLOURED PLATES 



7 ft ' v 



NEW YORK 
APPLETON AND COMPANY 
1897 



<V 4? A 

.^7 



Copyright, 1897, 
Br D. APPLETON AND COMPANY. 



VIRGIL P. GIBXEY, M.D., 

CLINICAL PROFESSOR OF ORTHOPAEDIC SURGERY IX THE COLLEGE OF PHYSICIANS 

AND SURGEONS (COLUMBIA UNIVERSITY), NEW YORK; SURGEON-IN-CHIEF 

TO THE HOSPITAL FOR THE RUPTURED AND CRIPPLED, 

THIS VOLUME IS INSCRIBED 

LB A TRIBUTE TO HIS PERSONAL WORTH AND HIGH PROFESSIONAL ATTAINMENTS, 
AND IN GRATEFUL REMEMBRANCE OF MANY ACTS OF KINDNESS, 

BY THE AUTnOR. 



PEEFACE. 



The rapid advance made during the past few years in this department 
of medicine is a sufficient justification, if one were needed, for another 
general work on the Diseases of Infancy and Childhood. It is not 
claimed that the present work is a complete one, for completeness in so 
broad a subject in a single volume is impossible. However, by omitting 
much material which does not strictly pertain to children, I have en- 
deavoured to give a somewhat full discussion of matters which are peculiar 
to early life, the space allotted to each subject being in some degree com- 
mensurate with its practical importance to the physician and student. I 
have intentionally avoided entering into a discussion of many questions 
which belong to general medicine and which are fully treated in works 
upon that subject. 

The pathology and symptomatology of disease in children who have 
passed their seventh or eighth year, really differ little from those of ado- 

ents and young adults. It is in infancy and early childhood only 
that the peculiar conditions exist which separate pediatrics from genera] 
medicine and entitle it to be ranked as a special department. These 
pages therefore are chiefly devoted to a consideration of the subjects of 
the nutrition and the diseases of infants and young children. 

The discussion of questions relating to operative surgery has been pur- 
posely omitted. What is said regarding surgical diseases has been from 
the standpoint of the physician, not that of the surgeon, and relates 
chiefly to symptoms and early diagnosis. 

Bather more space thai) is usual in a clinical work has been given 

to pathology and the description of lesions, my reasons for this being, 
first, that mosl of the processes which arc peculiar t<> very early life have 
received hut .-cant attention in works on pathology; secondly, such knowl- 
edge is absolutely indispensable to the correel understanding of these dis- 
eases clinically; and. thirdly, because I have been fortunate in having 

rathe]' exceptional opportunities for post-mortem study in connection 

with my clinical work. It is hoped that the drawings and photographs 
of pathological conditions which have been inserted will render this part 
of the work of interest to the general practitioner, and be of some assist- 
ance and value to those whose opportunities for the study <»f disease in 

v 



v i PREFACE. 

children are limited to the bedside. These illustrations have been se- 
lected with reference to their bearing on the symptomatology of disease 
and for the benefit of the practitioner, nofc the pathologist. In this as 
in all parts of the book I have tried to keep constantly in mind the 
every-day needs of the physician who practises among children and of 
the student who expects to do so. 

The material has been gathered from eleven years' continuous hospital 
service among young children, and much of the statistical matter which 
has been introduced, relates to cases which have been under my own ob- 
servation. 

While as a whole the book is very largely a record of personal experi- 
ence, I must express my great indebtedness to the rapidly increasing num- 
ber of active workers in paediatrics both in America and in Europe. 

The arrangement of the book differs somewhat from that of other 
works on the subject. The space given to nutrition, to its derangements, 
and to the diseases resulting therefrom, is, I think, not out of propor- 
tion to their importance. There can be little question regarding the 
propriety of placing rickets and scurvy in this class. It is hoped that the 
plan of grouping in a single chapter the various therapeutic measures use- 
ful in early life may aid the reader who wishes to consult the book on 
these points. In the parts relating to treatment, great, but I think not 
undue, stress has been laid upon diet and hygienic measures, since in 
them rather than in drug-giving lies the secret of success, certainly in all 
disorders of digestion and nutrition. 

The illustrations are for the greater part original, being either from 
photographs or drawings of my own cases. Most of the drawings are by 
Dr. Henry Macdonald. For all borrowed illustrations credit has been 
given. For some of the latter I wish to thank Messrs. William Wood & 
Co. and the J. B. Lippincott Company, who have allowed the use of cuts 
from their publications. 

I wish to express my obligations to Prof. James W. McLane, who 
kindly placed at my disposal the valuable records of the Sloane Maternity 
Hospital, from which the statistics relating to the newly-born child have 
been largely drawn. 

I am also deeply indebted to Drs. Charles G. Kerley and Martha Woll- 
stein for the tabulation of cases from hospital records and for other valu- 
able assistance ; to Dr. Thomas S. Southworth for suggestions in the 
chapter on Diseases of the Blood and for the preparation of the index ; to 
my brother, Dr. N. Curtice Holt, for the revision of the proof sheets of 
the entire book ; and, finally, to my publishers for their uniform courtesy 
and hearty co-operation at every stage of the work. 

L. Emmett Hoj/r. 

15 East Fifty-fourth Street, 

New York, November 25, 1896. 



TABLE OF CONTEXTS. 



PART I. 

CHAPTER PAGE 

L — Hygiene and General Care of Infants and Young Children . . 1 
Care of the newly-born child; bathing; clothing; care of the eyes; care of 
the mouth and teeth; care ut' the skin; care of the genital organs; vaccina- 
t i« »ii ; training to proper control of rectum and bladder; general hygiene of 
the nervous system ; sleep ; exercise; airing; the nursery; the nurse; the 
amount of air space required by infants; the care of premature and delicate 
infants; incubators ; the feeding of the premature infant. 

II. — Growth and Development of the Body . . . . .15 

Weight; height; growth of extremities as compared with the trunk; the 
heal; the chest; the abdomen; muscular development; development of spe- 
cial Benses; Bpeech; dentition. 
III. — Pei tuakities of Disease in Children .... 30 

Etiology; symptomatology and diagnosis; pathology; prognosis and infant 
mortality ; prophylaxis ; therapeutics. 

TART II. 
Section I.— Diseases of the Newly-Born. 

L— Asphyxia 87 

II. — Congenital Atelectasis 72 

III. I' TERU8 7.") 

[V. — The Acute Infectious Disi lsss of the Newly-Born ... 78 

The acnte pyogenic diseases ; ophthalmia ; tetanus ; epidemic heamoglobinuria ; 
fatty degeneration of the aewly-born; pemphigus. 

V.— HEMORRHAGES . 98 

Traumatic tal haemorrhages ; BpontaneottB heemorrh 

VI. — Birth Paralyses 106 

oral paralysis; facial paralysis; paralysis of the upper extremity. 

VII.— Tumours of nra Umbilicus, Mastitis, etc ill 

Umbilical hernia; mastitis; intestinal obstruction; diaphragmatic hernia; 
Mia ; inanition fever. 

Section II. Niti.tiion. 

L— Imtrobuctory 122 

The food constituenti rve in nutrition , 

vii 



viii TABLE OF CONTENTS. 

CHAPTER PAGE 

II.— The Infant's Dietary .126 

Woman's milk; cow's milk; condensed milk; kumyss; matzoon; junket, 
curds and whey ; beef preparations ; cereals ; infant foods. 

III. — Infant Feeding . . . 157 

Breast feeding ; maternal nursing ; wet-nursing ; weaning ; mixed feeding ; 
artificial feeding. 

IV. — Feeding after the First Year 185 

Healthy infants during the second year; difficult cases during the second 
year ; feeding from the third to the sixth year ; feeding during acute illness. 

V. — The Derangements of Nutrition 192 

Acute inanition ; malnutrition ; marasmus. 
VI. — Diseases due to Faulty Nutrition . . . . . . . . 209 

Scorbutus ; rickets. 

Section III. — Diseases of the Digestive System. 

I. — Diseases of the Lips, Tongue, and Mouth 238 

Malformations ; diseases of the lips ; diseases of the tongue ; alveolar abscess ; 
difficult dentition ; catarrhal stomatitis ; herpetic stomatitis ; ulcerative stoma- 
titis ; thrush ; gonorrheal stomatitis ; syphilitic stomatitis ; gangrenous stom- 
atitis. 

II. — Diseases of the Pharynx 256 

Acute pharyngitis ; uvulitis ; elongated uvula ; retro-pharyngeal abscess ; 
adenoid vegetations of the vault of the pharynx. 

III.— Diseases of the Tonsils . . . .268 

Follicular tonsillitis; phlegmonous tonsillitis; chronic hypertrophy of the 
tonsils. 

IV. — Diseases of the CEsophagus 274 

Malformations ; acute oesophagitis ; retro-cesophageal abscess. 

V. — Diseases of the Stomach 278 

Digestion in infancy ; malformations and malpositions of the stomach ; vom- 
iting ; cyclic vomiting ; gastralgia ; acute gastric indigestion ; acute gastritis ; 
gastro-duodenitis ; chronic gastric indigestion ; dilatation of the stomach ; 
ulcer of the stomach ; haemorrhage from the stomach. 

VI. — Diseases of the Intestines 306 

Malformations and malpositions ; diarrhoea ; acute intestinal indigestion. 

VII. — Diseases of the Intestines {continued) . 316 

Acute gastro-enteric infection ; cholera infantum. 

VIII. — Diseases of the Intestines {continued) 337 

Acute colitis and ileo-colitis ; chronic ileo-colitis ; amyloid degeneration of 
the intestines ; tuberculosis of the intestines and mesenteric lymph nodes. 

IX. — Diseases of the Intestines {continued) 363 

Chronic intestinal indigestion; intestinal colic; chronic constipation; intus- 
susception. 

X. — Diseases of the Intestines {continued) 389 

Appendicitis ; intestinal worms. 

XL — Diseases of the Rectum . . . 402 

Prolapsus ani ; fissures of the anus ; proctitis ; ischio-rectal abscess ; haemor- 
rhoids ; incontinence of faeces. 

XII. — Diseases of the Liver 408 

Icterus ; functional disorders ; acute yellow atrophy ; congestion of the liver ; 
abscess of the liver; cirrhosis; amyloid degeneration; fatty liver; hydatids; 
biliary calculi. 



TABLE OF CONTEXTS. 



IX 



CHAPTER PAGE 

XIII.— Diseases of the Peritoneum 415 

Acute peritonitis; chronic (non-tuberculous) peritonitis; tuberculous peri- 
tonitis ; ascites ; subphrenic abscess. 

Section IV.— Diseases of the Respiratory System. 
I.— Nasal Cavities 428 

Acute nasal catarrh ; chronic nasal catarrh ; chronic rhinitis ; pseudo-mem- 
branous rhinitis ; epistaxis. 

II. — Diseases of the Larynx 439 

Catarrhal spasm of the larynx ; acute catarrhal laryngitis; pseudo-membra- 
nous laryngitis; intubation; submucous laryngitis; chronic laryngitis; new- 
growths ; foreign bodice in the larynx. 

III.— Diseases of the Lungs 459 

The peculiarities of the lungs in infancy and early childhood ; acute catarrhal 
bronchitis; fibrinous bronchitis; chronic bronchitis; reflex cough ; asthma. 

IV. — Diseases of the Lungs {continued) 477 

Pneumonia; acute broncho-pneumonia. 

V.— Diseases of the Lungs {continued) 514 

Lobar pneumonia ; pleuro-pneumonia ; hypostatic pneumonia ; chronic bron- 
cho-pneumonia ; gangrene of the lung; acquired atelectasis; emphysema. 

VI.— Pleurisy 543 

Dry pleurisy; pleurisy with serous etfusion ; empyema. 

Section V. — Diseases of the Circulatory System. 

I. — PECULIARITIES OF THE HEART AND CIRCULATION IN EARLY LlFE . . 558 
II. — CONGENITAL ANOMALIES OP Till. HEART 562 

III. — Pericarditis 569 

pericarditis; chronic pericarditis with adhesions. 

IV. — Endocarditis and Valvular Disease 574 

locarditis; malignant endocarditis ; chronic valvular die 
myocarditis; ansamic murmurs; functional disorders of the heart ; diseae 

the blow. 

Section VI.— Disk asks of the Uro-Genital Stbtem. 

I._Tiii. Ckini: in [nFANCY LND CHILDHOOD 

Functional or cyclic albuminuria; hematuria; hemoglobinuria; glycosuria ; 
pyuria; lithuria; indioanuria; aoetonuria; diaoetonuria ; anuria; diabetes 
insipidus, 

II. — Diseases <»i thi Kidneys 606 

■ .\ malposil acid infections; acute congestion of the 

kidneys; chronic congestion of tin- kidneys; an,- ration of tin- kid 

lative nephritis ; acute diffuse nephritis; chronic nephritis; 
tuberculosis of the kidney ; malignant tumours of the kidney ; pyelitis; renal 
oalouli ; traumatic hydro-nephrosis ; perinephritis ; general oedema nol de 
pendent <'ii renal dis< 

HI. — Diseases of thi Genital Oroans 

nitals. 

[V.— Enuresis . 644 

;ii spasm ; vesioal •ul'iili. 



TABLE OF CONTENTS. 



Section VII.— Diseases of the Nervous System. 

CHAPTER PAGE 

I. — Introductory 651 

II. — General and Functional Nervous Diseases 653 

Convulsions ; epilepsy ; tetany ; laryngismus stridulus ; chorea ; other spas- 
modic affections ; hysteria ; headaches ; disorders of speech ; disorders of 
sleep; injurious habits of infancy and childhood. 

III. — Diseases of the Brain and Meninges . •. . . . . 699 

Malformations ; pachymeningitis ; acute meningitis ; tuberculous meningitis ; 
chronic basilar meningitis in infants ; thrombosis of the sinuses of the dura 
mater ; cerebral abscess ; cerebral tumour ; hydrocephalus ; infantile cerebral 
paralysis ; feeble-mindedness, idiocy, imbecility ; sporadic cretinism ; insan- 
ity ; the stigmata of degeneration ; deaf-mutism. 

IV. — Diseases of the Spinal Cord 759 

Malformations ; spinal meningitis ; myelitis ; compression-myelitis ; infantile 
spinal paralysis ; tumours of the spinal cord ; syringo-myelia ; Friedreich's 
ataxia ; Landry's paralysis ; the muscular atrophies. 

V. — Diseases of the Peripheral Nerves 785 

Multiple neuritis ; diphtheritic paralysis ; facial paralysis. 



Section VIII. — Diseases of the Blood, Lymph Nodes, Bones, etc. 

I. — Diseases of the Blood 795 

Simple anaemia; chlorosis; pseudo-leucaemic anaemia of infancy; pernicious 
anaemia; leucaemia; haemophilia; purpura. 

II. — Diseases of the Lymph Nodes . . ' . . . . . . . 816 

Lymphatism ; simple acute adenitis ; simple chronic adenitis ; syphilitic ade- 
nitis ; tuberculous adenitis ; Hodgkin's disease. 

III. — Diseases of the Spleen 832 

IV. — Diseases of the Bones and Joints 835 

Acute arthritis of infants ; tuberculous diseases of the bones and joints ; syph- 
ilitic diseases of bone. 

V. — Diseases of the Skin 858 

Congenital ichthyosis; miliaria; seborrhoea; eczema; furunculosis ; gangre- 
nous dermatitis ; impetigo contagiosa ; urticaria ; scabies ; tinea tonsurans. 
VI. — Acute Otitis 879 

Section IX. — The Specific Infectious Diseases. 

I. — Scarlet Fever 888 

II. — Measles 910 

III. — Rubella 995 

IV. — Varicella 909 

V. — Vaccinia — Vaccination . . . , ■. 931 

VI. — Pertussis 936 

VII. — Mumps 947 

VIII. — Diphtheria 951 

IX.— Typhoid Fever 1008 

X.— Tuberculosis . 1016 



TABLE OF CONTENTS. x j 

CHAPTER PAGE 

XL— Syphilis 1052 

XII.— Influenza 1069 

XIIL— Malaria 1073 

Section X. — Other General Diseases. 

L— Rheumatism 1085 

II. — Diabetes Mellitus 1091 



LIST OF ILLUSTRATIONS. 



PLATES. FACING 

PAGE 

1. Chart showing by months the mortality of New York city for the dif- 
ferent ages for three years 41 

II. Meningeal haemorrhage in the newly-born 106 

III. Chart showing composition of various infant foods compared with 

woman's milk 157 

IV. Bone in rickets 219 

V. Typical riekets 222 

VI. Deformity of the chest in severe rickets 225 

VII. The stomach at the different periods of infancy 278 

VIII. Extensive catarrhal ulceration of the colon :i4l 

IX. Deep follicular ulcers of the colon :)42 

X. Membranous inflammation of the ileum 344 

XI. Chronic hyperplasia of the Lymph nodules (solitary follicles) of the 

colon 364 

XII. Acute broncho-pneumonia • . 484 

XIII. Acute pleuro-pneumonia r>:!-j 

XIV. Chronic broncho-pneumonia 585 

XV. Acute meningitis, complicating pleuro-pneumonia 707 

XVI. The blood in lucaBmia and pernicious anaBmia 796 

XVII. The diphtheritic membrane 066 

XVIII. Diphtheria bacilli and their associates ' 977 

XIX. Tuberculosis of the tracheo-bronchial lymph nodes 1028 



ILLUSTRATIONS IX THE TEXT. 

IMUBI PAGE 

1. Incubator 12 

2. Incubator, Bectiou view 18 

8, i. Scales L6 

5. Weight curve for the firs! twenty days 18 

(>. Weight curve fortheflrsl year 1 st 

7. Skull, showing premature ossiflcatioo ........ 

8. Apparatus for albolene spray 

9. Nasal syringe 

10. Position for nasal syringing 

11. ('roup kettle 

18, Vapourizer 59 

xiii 



x iv LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

13. Steam atomizer 59 

14. Oiled-silk jacket 59 

15. Apparatus for stomach-washing 60 

16. Position for stomach- washing . . . . _ . . . . .61 

17. Colon of a child six months old 64 

18. Ribemont's tube 71 

19. Erb's paralysis 110 

20. Umbilical tumours . 112 

21. Temperature chart in inanition fever . . - . . . . . . 120 

22. Human milk, colostrum period 127 

23. Human milk, later period 127 

24. Apparatus for examination of human milk . , ■ 132 

25. Feser's lactoscope 140 

26. Cow's milk, showing creamy layer . . 142 

27. Cooley creamer, cans 143 

28. Arnold sterilizer 144 

29. Freeman Pasteurizer . 146 

30. Weight chart, showing effect of pregnancy 168 

31. Case of marasmus 206 

32. Normal bone 220 

33. Rachitic bone . . .221 

34. Rachitic skull, inside view 224 

35. Rachitic head 225 

36. Rachitic skull, external view 226 

37. Rachitic thorax in outline 226 

38. Rachitic bow-legs . 227 

39. Rachitic knock -knees . . . . . 228 

40. Rachitic deformity' of legs 229 

41. Rachitic bow-legs in outline 236 

42. Epithelial desquamation of the tongue 241 

43. Thrush 251 

44. Cancrum oris . . . . . . • 255 

45. Chest deformity from adenoid vegetations of the pharynx .... 265 

46. 47. Child with adenoid vegetations, before and after operation . . . 267 

48. Dilatation of the stomach 303 

49. Malformations of the rectum 307 

50. Chart showing mortality from diarrhceal diseases in New York . . . 309 

51. Chart showing frequency of diarrhceal diseases 309 

52. Acute catarrhal ileo-colitis, superficial type 339 

53. Acute catarrhal ileo-colitis, severe form 340 

54. Follicular ulceration of the colon, early stage . . . . . . . 342 

55. Follicular ulceration of the colon, later stage 343 

56. Membranous colitis 345 

57. Temperature chart in ileo-colitis 348 

58. Temperature chart in membranous colitis 349 

59. Chronic catarrhal inflammation of the ileum 355 

60. Ileo-ccecal intussusception 379 

61. 62. Mechanism of intussusception . 380 

63. Taenia saginata 396 

64. Taenia solium 396 

65. Taenia cucumerina ............ 397 



LIST OF ILLUSTRATIONS. 



XV 



FIGURE 

66. Bothriocephalic latus 

07. Acaris luinbricoides 

68. Oxyuris vermicularis 

69. Prolapsus ani 

70. Apparatus for calomel fumigation 

71. O'Dwyer's intubation set 

72. An air vesicle in broncho-pneumonia .... 
To. An air vesicle in lobar pneumonia 

74. Broncho-pneumonia with thickened bronchus . 

75. Broncho-pneumonia, hemorrhagic form .... 

76. Broncho pneumonia, early stage of 

77. Broncho-pneumonia with emphysema .... 

78. Broncho-pneumonia with thickened bronchus . 

79. Broncho-pneumonia, diffuse purulent infiltration . 

80. Broncho-pneumonia, diffuse purulent infiltration . 

81. Persistent bronchopneumonia 

82. Temperature chart in mild uncomplicated broncho-pneumon 

83. Temperature chart, prolonged course, broncho-pneumonia 

84. Temperature chart, relapsing broncho-pneumonia . 
s "i. Temperature chart, rapidly fatal broncho-pneumonia 
86-89. Physical signs in broncho-pneumonia .... 
90. Temperature chart, persistent broncho-pneumonia . 
ill. Temperature chart, broncho-pneumonia following pertussis 
98. Temperature chart, typical lobar pneumonia . 
93. Temperature chart, remit tent type, Lobar pneumonia 
( Jl. Temperature chart, lobar pneumonia, subnormal temperature 
95. Temperature chart, abortive pneumonia .... 

>8. Physical signs, lobar pneumonia 

!»!». Section of Iutilt. showing distribution of fluid in chest . 

100. Deformity after old empyema 

101. Apparatus for inducing lung expansion after empyema . 
108. Showing normal areas of cardiac dulness , 

108. Congenital cardiac disease 

104. Clubbing of fingers in congenital cardiac disease 
106. Congenita] malformation-, of the kidney and ureters 
100, 107. Sarcoma of the kidney before and alter operation . 

10a Tetany 

100. Spasmodic tori icollis 

110. Meningocele 

111. Bncephalooele 

112. Bydrencjephalocele 

1 18. Naso-frontal meningocele 

ill. Tracing of respiration in tuberculous meningitis 

11"). Temperature chart in tuberculous meningitis . 

118. Chronic basilar meningitis ...... 

117. Section of the brain in hydrocephalus .... 

118. Bead in chronic hydrocephalus, globular form 
ii!i. Bead in chronio hydrocephalus, pyramidal form 
ISO. Brain, Bhowing results of old meningeal hemorrhage, lateral new 
121. Brain, Bhowing results of old meningeal hemorrhage, superior ri 

Convulsions in infantile cerebral paral] .... 



after cri 



PAGE 

397 
398 
400 
403 
448 
451 
478 
479 
484 
486 
487 
488 
489 
490 
491 
492 
497 
498 
498 
498 
500 
503 
504 
520 
620 
521 
521 
525 
550 
555 
556 
561 
568 
566 
(i< in 
626 
670 
688 
688 
698 
699 

roo 



X vi LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

123. Contractures following infantile cerebral paralysis 748 

124. Brain in idiocy 751 

125. A typical cretin . . . 752 

126-128. Cretin, showing effect of thyroid treatment 753 

129. Spina bifida, meningocele (partially diagrammatic) 760 

130. Spina bifida, meningocele, case of 760 

131. Spina bifida, meningo-myelocele (partially diagrammatic) .... 761 

132. Spina bifida, syringo- myelocele 762 

133. Spina bifida, sacral 762 

134. Spina bifida, section of cord in 763 

135. Infantile spinal paralysis of lower extremity . . 774 

136. Infantile spinal paralysis of shoulder . . 775 

137. Pseudo-muscular hypertrophy 784 

138. Alcoholic neuritis . . . . . •» . 787 

139. Diphtheritic paralysis i - . . . 788 

140. Facial paralysis 793 

141. Acute suppurative adenitis, cervical 821 

142. Acute suppurative adenitis, inguinal . . . . . . . 821 

143. Cicatrices following tuberculous adenitis . . . . . . . . 828 

144. Section of the spine in Pott's disease ........ 839 

145. Hip-joint disease 845 

146. Tuberculous dactylitis 850 

147. Syphilitic disease of the radius and ulna 852 

148. Syphilitic disease of the tibia 854 

149. Syphilitic disease of both tibiae , 855 

150. Syphilitic necrosis of the tibia 856 

151. Syphilitic dactylitis . . . .857 

152. Congenital ichthyosis 859 

153. Mastoid abscess 883 

154. Temperature chart in scarlet fever, typical curve 893 

155. Temperature chart in scarlet fever, prolonged course 894 

156. Temperature chart in complicated scarlet fever 896 

157. Temperature chart in fatal septic scarlet fever 897 

158. 159. Temperature charts in measles, typical curve 916 

160. Temperature chart in measles, occasional course 917 

161. Temperature chart in measles, prolonged course 917 

162. 163. Temperature charts in measles complicated by pneumonia . . . 918 

164. Vaccination vesicles, normal 934 

165. Vaccination vesicles, severe course . . . 934 

166. Chart showing mortality from diphtheria with and without antitoxine . . 994 

167. Chart showing mortality from diphtheria and croup in Berlin, Paris, and 

New York * . .996 

168. Chart showing mortality from diphtheria in Chicago 997 

169. Temperature chart in pseudo-diphtheria 1005 

170. Temperature chart in typhoid fever, short course 1011 

171. Temperature chart in typhoid fever with relapse 1012 

172. Tuberculous broncho-pneumonia, diffuse consolidation 1025 

173. Cavity from tuberculous broncho-pneumonia 1025 

174. A tuberculous nodule 1026 

175. Tuberculous broncho-pneumonia, early stage . 1027 

176. Tuberculous bronchial lymph nodes 1029 



LIST OF ILLUSTRATIONS. xv jj 

FIGURE PAGE 

177. Temperature chart of tuberculosis following measles 1038 

178. Temperature chart of tuberculous broncho-pneumonia, general tuberculosis . 1039 

179. Temperature chart of tuberculous broncho-pneumonia with softening . . 1040 

180. Syphilitic notched teeth 10G2 

181. Syphilitic screw-driver teeth 1063 

182. Temperature chart of acute broncho-pneumonia complicating influenza . 1072 

183. Temperature chart, quotidian intermittent fever 1077 

184. Temperature chart, tertian intermittent fever 1078 

185. Temperature chart in malaria, irregular type 1080 



THE DISEASES OF INFANCY AND CHILDHOOD. 

PART L 



CHAPTER I. 

HYGIENE AND GENERAL CARE OF INFANTS AND YOUNG 

CHILDREN. 

The physical development of the child is essentially the product of 
the three factors — inheritance, surroundings, and food. The first of these 
it is beyond the physician's power to alter ; the second is largely and the 
third almost entirely within his control, at least in the more intelligent 
classes of society. These two subjects, infant hygiene and infant feeding, 
are the most important departments of pediatrics. 

The Care of the Newly Born Child. — After the ligature of the cord the 
child should be wrapped in a thick blanket and placed in a warm room. 
In hospital practice the eyes should be cleansed with absorbent cotton 
and water which has been boiled, and then two or three drops of a two- 
per-cent solution of nitrate of silver, after Crede's method, instilled into 
each eye by means of a glass rod or eye-dropper. In private practice a 
saturated solution of boric acid may be substituted, unless the mother has 
had a purulent vaginal discharge, in which case the silver solution should 
always be used. The bath should now be given in a warm room ; the 
body being first oiled thoroughly in order to remove the vernix caseosa 
and then washed in water at a temperature of 10C° F. The mouth should 
be cleansed with plain tepid water and a soft cloth, and no violence em- 
ployed. The cord may be covered with salicylic acid one part and starch 
nineteen parts, or simply with subnitrate of bismuth, and wrapped in ab- 
sorbent cotton or surgeon's lint. The abdomen should now be enveloped 
in a flannel band, eight or ten inches wide, and pinned rather snugly. 
Before dressing is completed, the child should be submitted to a thorough 
examination for injuries received during delivery, congenital deformities, 
also as to the condition of the respiration, circulation, etc. 

After dressing, the child should be placed in its crib and covered with 
blankets, and if the feet are cold, or the fingers and lips a little blue, it 



2 HYGIENE AND GENERAL CARE OF INFANTS. 

should be surrounded by hot-water bottles covered with flannels, and 
placed near, but not in contact with, the body. The crib should be placed 
in a quiet, darkened room. The young infant should not occupy the 
same bed as the mother, unless it greatly needs the warmth of her body, 
other means of artificial heat not being at hand. 

The cord should be kept dry and disturbed as little as possible until 
it falls off. Under ordinary circumstances the cord separates from the 
fourth to the seventh day, the average being the fifth day. The stump 
should then be covered with the salicylic acid and starch powder, and a 
pad of muslin about one fourth of an inch thick and two inches square 
applied and secured in position by means of the abdominal band. The 
purpose of this is to prevent umbilical hernia. The pad should be con- 
tinued for the first month. The use of stronger antiseptic dressings than 
that recommended is somewhat objectionable, since it preserves the cord 
too long and delays separation. The full bath should not be given until 
the cord has separated. 

The physician should always see to it that the infant cries enough to 
keep the lungs properly expanded. 

The question of food for the newly born infant is considered in the 
chapter upon infant feeding. 

Bathing. — For the first few months the bath should be given at 98° 
F. The room should be warm, preferably there should be an open fire. 
The bath should be short and the body dried quickly, without too vigor- 
ous rubbing. The addition of salt to the bath is an advantage where the 
skin is unusually delicate or excoriations are present. One large handful 
should be used to a gallon of water. By the sixth month the temperature 
of the bath for healthy infants may be lowered to 95° F., and by the end 
of the first year to 90° F. Older children who are healthy should be sponged 
or douched for a moment at the close of the tepid bath with water at 65° 
or 70° F. During childhood the warm bath is preferably given at night. 
In the morning a cold sponge bath is desirable. This should be given in 
a warm room and while the child stands in a tub partly filled with warm 
water. This cold sponge should last but half a minute, and be followed 
by a brisk rubbing of the entire body. 

In some young infants and even older children there is no proper 
reaction after the bath, even when given at the temperatures mentioned ; 
children being pale, slightly blue about the lips and under the eyes. All 
tub bathing, and especially all cold bathing, should then be stopped, since 
a continuance can only be a drain upon the child's vitality. 

Clothing. — The clothing of infants should be light, warm, non-irri- 
tating to the skin, and loose enough to allow free motion of the extremi- 
ties ; nor should bands be pinned so tightly about the trunk as to em- 
barrass the movements either of the chest or of the abdomen. The chest 
should be covered with a woollen shirt, high in the neck and with long 



BATHING— CLOTHING. 3 

sleeves. All petticoats should be supported from the shoulders and not 
from waistbands. Canton flannel and stockinet are both superior as 
absorbents to the more commonly used linen diapers. Stockinet has the 
advantage of being very soft and pliable. Care should be given that in in- 
fants the feet be kept warm. If the circulation is very poor, a bag of hot 
water should always be in the crib. Cold feet are responsible for many 
attacks of colic and indigestion. 

The abdominal band is usually worn during infancy. It cannot be 
considered in any sense a necessity after the first few months, excepting 
in cases of very thin infants whose supply of fat in the abdominal walls is 
an insufficient protection to the viscera. For the first few weeks a band of 
plain flannel is to be preferred ; later, a knitted band with shoulder-straps. 
The fashion of low neck and short sleeves for infants and very young 
children has fortunately passed away — let us hope, never to return. 

During the summer the outer clothing should be light and the under 
clothing of the thinnest flannel or gauze. The changes in the tempera- 
ture of morning and evening may be met by extra wraps. The custom of 
allowing young children to go with legs bare has many enthusiastic advo- 
cates; while it may not be objectionable during the heat of summer, its 
advantages at any season are very questionable in a changeable climate 
like that of New York or the Atlantic coast. Many delicate children are 
certainly injured by such ill-advised attempts at hardening. 

The night clothing of infants should be similar to that worn during 
the day, but should be loose, the material being of the lightest flannel. 
The night clothing for older children should consist of a thin woollen 
shirt and a union suit with waist and trousers, and in some cases with 
feet, if there is a .tendency to get outside the coverings. The common 
mistake is to overload all children, but especially infants, with covering at 
night. This is an explanation of much of the restless sleep which is seen 
particularly in delicate children. 

Care of the Eyes. — During the first few days at the daily bath, the 
eyes should be cleansed with a saturated solution of boric acid. They 
should be carefully protected from too strong light during early infancy. 
It is desirable that a child should always sleep in a darkened room. 

Care of the Mouth and Teeth. — The mouth of the newly born infant 
should be gently cleansed at each morning bath with boiled water and 
a soft cloth. On the first appearance of thrush the mouth should be 
washed after every feeding with a solution of bicarbonate of soda or borax 
(twenty grains to the ounce). Harm is often done by the use of too much 
force in cleansing the mouth of a young infant. 

The primary teeth as well as those of the permanent set should receive 
daily attention. Too often they are neglected altogether. Dirty teeth 
are likely sooner or later to become carious ; and carious teeth, besides 
being a cause of bad breath and neuralgia, are a constant menace to the 



4 HYGIENE AND GENERAL CARE OF INFANTS. 

health of the child, since they may harbour infectious germs of all varie- 
ties. Such teeth should either be filled or removed. 

Care of the Skin. — The skin of a young infant is exceedingly deli- 
cate, and excoriations, intertrigo, and eczema are of very common occur- 
rence. These conditions are much easier of prevention than of cure. 
The first essential in the care of the skin is cleanliness, and this must be 
secured without the use of strong soaps or too much rubbing. Napkins 
must be removed as soon as soiled or wet. Some bland absorbent powder, 
like starch, talcum, or the stearate of zinc, should be used in all the folds 
of the skin, in the neck, in the axillaB, groins, and about the genitals, and 
in the folds of the thighs, particularly in very fat infants. If plain water 
produces an undue amount of irritation, the salt or bran bath should be 
employed. 

Care of the Genital Organs. — The female genitals need but little 
attention in young children, excepting as to cleanliness. This is more 
often neglected in older children than in infants. Vulvo-vaginitis is very 
common among the children of the poorer classes where cleanliness is 
neglected. 

In males the prepuce should receive attention during the first few 
weeks of life. If the foreskin is long and the preputial orifice small, 
circumcision should invariably be done. If it is not long, but is only 
adherent, these adhesions should be broken up, the parts thoroughly 
cleansed and the foreskin retracted daily until there is no disposition to a 
recurrence of the adhesions. These operations will be discussed more at 
length in a subsequent chapter. The only thing to be emphasised in 
the present connection is that the prepuce should receive proper atten- 
tion in early infancy, since this can now be done with less pain and dis- 
comfort to the child, and at the same time better results are obtained. 
If this matter is neglected during infancy, it is apt to be overlooked until 
harm has been produced by local or reflex irritation which phimosis or 
adherent prepuce may have excited. 

Vaccination. — This, although considered elsewhere, should be men- 
tioned in this connection as among the things requiring the physician's 
attention during the first months of life. 

Training to Proper Control of Rectum and Bladder. — It is surpris- 
ing to see what can be accomplished by intelligent efforts at training 
in these particulars. An infant can often be trained at three months to 
have its movements from the bowels when placed upon a small cham- 
ber. This not only saves a great amount of washing of napkins, but 
there is soon formed a habit of having the bowels move at a regular time 
or times each day. The infant must be put upon the chamber soon after 
its feeding. The importance of training young children to regular habits 
regarding evacuations from the bowels can hardly be overestimated. It 
should be impressed upon every mother and nurse by the physician, and 



SLEEP. 5 

especially the necessity of beginning training during infancy. Much of 
course will depend upon the food and the digestion ; but habit is a very 
large factor in the case. 

The training of the bladder is not quite so important, but the proper 
education of this organ adds much to the comfort of the child and the ease 
with which it is cared for. Before the end of the first year most intelli- 
gent children can be trained to indicate a desire to empty the bladder. 
Many mothers and nurses succeed in training children so well that by the 
tenth or eleventh month napkins are dispensed with during the day. 
On the other hand, it is very common to see children of two and even two 
and a half years still wearing napkins because of the lack of proper train- 
ing. Before it has reached the latter age a healthy child should go from 
10 P. M. until morning without emptying the bladder. The annoyance 
and discomfort from the neglect of early training in this particular are 
very great. Night feeding is responsible for much of the difficulty expe- 
rienced in training children to hold the water during the night. 

General Hygiene of the Nervous System. — Great injury is done to 
the nervous system of children by the influences with which they are 
surrounded during infancy, especially during the first year. The brain 
grows more during the first two years than in all the rest of life. Normal 
healthy development of the nervous centres demands quiet, rest, peaceful 
surroundings, and freedom from everything which causes excitement or 
undue stimulation. 

The steadily increasing frequency of functional nervous diseases among 
young children is one of the most powerful arguments for greater atten- 
tion by physicians to the subject of the hygiene of the nervous sys- 
tem during infancy. Most parents err through ignorance. Playing with 
young children, stimulating to laughter and exciting them by sights, 
sounds, or movements until they shriek with apparent delight, may be a 
source of amusement to fond parents and admiring spectators, but it is 
almost invariably an injury to the child. This is especially harmful when 
done in the evening. It is the plain duty of the physician to enlighten 
parents upon this point, and insist that the infant shall be kept quiet, and 
that all such playing and romping as has been referred to shall, during 
the first year at least, be absolutely prohibited. 

Sleep. — The sleep of the newly born infant is profound for the first 
two or three days and under normal conditions almost continuous. In 
the case of prolonged or tedious labor, or where from any cause undue 
compression has been exerted upon the head, it may approach the con- 
dition of semi-coma for twenty-four or forty-eight hours. This may be so 
deep as to excite apprehensions of serious brain lesions. If, however, there 
are associated with it no convulsions and no rigidity, this early stupor 
usually passes away on the second or third day. 

The sleep of early infancy is quiet and peaceful, but not very deep after 



6 HYGIENE AND GENERAL CARE OF INFANTS. 

the first month. After the third year the heavy sleep of childhood is 
commonly seen. A healthy infant during the first few weeks sleeps from 
twenty to twenty- two hours out of the twenty-four, waking only from 
hunger, discomfort, or pain. During the first six months a healthy infant 
will usually sleep from sixteen to eighteen hours a day, the waking pe- 
riods being only from half an hour to two hours long. At the age of one 
year most infants sleep from fourteen to fifteen hours, viz., from eleven 
to twelve hours at night, and two or three hours during the day, usually 
in two naps. When two years old usually thirteen to fourteen hours' 
sleep are taken ; eleven or twelve hours at night and one or two hours 
during the day, generally in a single nap. At the age of four years chil- 
dren require from eleven to twelve hours' sleep. It is always desirable, 
and in most cases with regularity it is possible, to keep up the daily nap 
until children are four years old. From six to ten years the amount of 
sleep required is ten or eleven hours, and from ten to sixteen years nine 
hours should be the minimum. 

Training in proper habits of sleep should be begun at birth. From 
the outset an infant should be accustomed to being put into its crib while 
awake and to go to sleep of its own accord. Eocking and all other habits 
of this sort are useless and may even be harmful. An infant should not 
be allowed to sleep on the breast of the nurse, nor with the nipple of the 
bottle in its mouth. Other devices for putting infants to sleep, such as 
allowing the child to suck a rubber nipple or anything else, are positively 
injurious. If such means of inducing sleep are resorted to the infant soon 
acquires the habit of not sleeping without them. I have known of one 
instance where the habit of rocking during sleep was continued until the 
child was two years old ; the moment the rocking was stopped the infant 
would wake, and in consequence this practice was continued by the de- 
voted but misguided parents. A quiet, darkened room, a warm and com- 
fortable bed, an appetite satisfied, and dry napkins are all that are needed 
to induce sleep in a healthy child. 

The periods of sleep in young infants are usually from two to three 
hours long, with the exception of once or twice in the twenty-four hours, 
when a long sleep of five or six hours occurs. The purpose of training 
is to have the child take this long sleep at night. The habit of regular 
sleep is best established by wakening the infant regularly every two or 
two and a half hours during the day for feeding, and allowing it to sleep 
as long as possible during the night. This training goes hand-in-hand 
with regular habits of feeding. Such habits are easily formed if the plan 
be systematically followed from the outset. 

By the fifth month all feeding between 10 p. m. and 7 A. M. should be 
discontinued. If this is done most infants can be trained by this time to 
sleep all night. If the room is lighted, and the child taken from the crib 
or rocked or fed as soon as it wakens at night, there is no such thing as 



EXERCISE. 7 

the formation of good habits of sleep. Eegularity in sleep and feeding 
not only make the care of young infants very much easier, but they are of 
a good deal of importance for the health of the child. 

The causes of disturbed or irregular sleep in young infants are mainly 
two — hunger and indigestion. In nursing infants it is usually the for- 
mer ; in those artificially fed usually the latter. Sleeplessness from hun- 
ger is often seen in children who are nursed thirty or forty minutes and 
then fall asleep, but wake in fifteen or twenty minutes crying and fretful. 
After being quieted they may fall asleep again for half an hour, but wake 
at short intervals. The peaceful sleep of two or three hours which should 
follow a proper feeding is never seen. With this restlessness other signs 
of indigestion are usually present, such as bad stools, stationary weight, 
etc. The disturbed sleep due to overfeeding shows itself by much the 
same symptoms, excepting that the first sleep after the meal is usually 
longer. 

Exercise. — This is no less important in infancy than in later child- 
hood. An infant gets its exercise in the lusty cry which follows the cool 
sponge of the bath, in kicking its legs about, waving its arms, etc. By 
these means pulmonary expansion and muscular development are in- 
creased and the general nutrition promoted. An infant's clothing should 
be such as not to interfere with its exercise. Confinement of the legs 
should not be permitted. In hospital practice I have often had a chance 
to observe the bad results which follow when very young infants are 
allowed to lie in the cribs nearly all the time. Little by little the vital 
processes flag, the cry becomes feeble, the weight is first stationary, then 
there is a steady loss. The a]3petite fails so that food is at first taken 
without relish, then at times altogether refused; later, vomiting ensues 
and other symptoms of indigestion. This, in many cases, is the begin- 
ning of a steady downward course which goes on until a condition of hope- 
less marasmus is reached. Such infants must be taken up every few 
hours and carried about the wards ; the position should be frequently 
changed, and general friction of the entire body employed at least twice a 
day. Every means must be made use of to stimulate the vital activity. 
The value of systematic attention to these matters cannot be overestimated 
in hospitals for infants. Infants who are old enough to creep or stand 
usually take sufficient exercise unless they are restrained. At this age 
they should be allowed to do what they are eager to do. Every facility 
should be afforded for using their muscles. Exercise may be encouraged 
by placing upon the floor in a warm room a mattress or a thick " com- 
fortable," and allowing the infant to roll and tumble upon it at will. A 
large bed may answer the same purpose. 

In older children every form of out-of-door exercise should be encour- 
aged — ball, tennis, and all running games, horseback riding, the bicycle, 
tricycle, swimming, coasting, and skating. Up to the eleventh year no 



8 HYGIENE AND GENERAL CARE OF INFANTS. 

difference need be made in the exercise of the two sexes. Companion- 
ship is a necessity. Children brought up alone are at a great disadvantage 
in this respect, and are not likely to get as much exercise as they require. 
The amount of exercise allowed delicate children should be regulated 
with some degree of care. It may be carried to the point of moderate 
muscular fatigue, but never to muscular exhaustion. The latter is partic- 
ularly likely to be the case in competitive games. 

Exercise should have reference to the symmetrical development of the 
whole body. In prescribing it the specific needs of the individual child 
should be considered. By carefully regulated exercises very much may be 
done to check such deformities as round shoulders and slight lateral cur- 
vature of the spine, and also to develop narrow chests and feeble thoracic 
muscles. For purposes like these, gymnastics are exceedingly valuable to 
supplement out-of-door exercise, but they can never take their place. 

There are two important points with reference to exercise indoors : 
First, the playroom should be cool — from 60° to 65° F. ; never above 
this point. Secondly, during all active exercise the clothing should be 
loose and light, so as to allow the freest possible motion of the body. 

Airing. — In summer there can be no possible objection to a young 
infant being allowed out of doors at the end of the first week. It should 
be kept in the open air as much as possible during the day. In the fall 
and spring this should not be permitted until the child is at least a month 
old, and then only when the out-of-door temperature is above 60° F. 
During its outing the head should be protected from the wind and the 
eyes from the sun. The duration of the outing at first should be only fif- 
teen or twenty minutes, the time being gradually lengthened to two or 
three hours. The infant should be gradually accustomed to changes of 
temperature in the room by opening wide the windows for a few min- 
utes each day even before it is taken out of doors, the child being dressed 
meanwhile as for an outing. In the case of children born late in the 
fall or in the winter this means of giving fresh air may be advantageously 
begun at one month and followed throughout the first winter. It is only 
necessary in all such cases that the changes be made very gradually 
both as to the length of the airing and to the temperature. The great 
advantage of this plan over that more commonly followed of keeping 
young infants closely housed for the first six months in case they are born 
in the fall or early winter, I can positively affirm from quite a wide obser- 
vation of both methods. It is a matter of very serious importance that 
every infant be furnished an abundance of pure fresh air in winter as well 
as in summer. When the plan above outlined is carefully and judiciously 
followed, the tendency to catarrhal affections instead of being increased is 
thereby greatly lessened. 

When four or five months old, there is no reason why a healthy child 
should not go out of doors on pleasant days if the temperature is not 



NURSERY. o, 

below 20° F. While there is a prejudice on the part of many mothers 
and some physicians against a child's sleeping out of doors in cold 
weather, it is a practice which I have always urged upon mothers, and 
have never seen followed by any but the most beneficial results. The 
days of all others when infants and very young children should not be 
out of doors are when there are high winds, especially those from the 
northeast, an atmosphere of melting snow, and during severe storms. 
Delicate infants must of course be more carefully guarded during the 
cold season. With most of these the plan of house-airing is all that 
should be attempted. 

Nursery. — This should be the sunniest and best-ventilated room in 
the house. It is the physician's duty to see that proper attention is paid 
to the hygiene of the room in which the child spends at least four fifths of 
its time during the first year, and two thirds of its time during the first 
two or three years of life. Sunlight is absolutely indispensable. Sunny 
rooms always contain less organic matter and less humidity, and hence a 
room upon the north side of the house should always be avoided, prefera- 
bly one in the second story should be chosen. Nothing which can in any 
way contaminate the air of the room should be allowed. There should be 
no drying of clothes or of napkins, and no plumbing. No food should be 
allowed to stand about the room. The gas should not be allowed to burn 
at night ; a small wax night-light furnishes all that is needed in the 
nursery. If possible the heat should be from an open fire ; the next best 
thing is the Franklin radiator. Nothing in the room is worse than steam 
heat from a radiator unless it be a gas stove which under no circumstances 
should be allowed, excepting possibly for a few minutes each morning dur- 
ing the bath. 

The temperature of the room during the day should be 70° F., but 
better 68° than 72° F. It is important that every nursery should have a 
thermometer, and that this and not the sensations of the nurse should be 
the guide. It is almost invariably true that the nursery is overheated. 
Often no other explanation can be found for chronic indigestion and fail- 
ing weight excepting a nursery whose habitual temperature ranges from 
75° to 80° F. At night for the first few months the temperature should 
not be allowed to fall below 65° F. After the first year the night tem- 
perature may fall to 60° or even 55° F. 

Free ventilation without draughts is an absolute necessity. This is best 
accomplished by ventilators in the windows, of which there are many ex- 
cellent devices sold in the shops. While the child is absent from the room 
the windows should be widely opened and free airing of the nursery ac- 
complished. The room should always be thoroughly aired at night before 
the child is put to bed. The window may be kept open even in the first 
year, unless the temperature out of doors is below 40° F. After the first 
year the window may be open, unless the outside temperature is as low as 



10 HYGIENE AND GENERAL CARE OF INFANTS. 

20 e F. If the window is open the door of the nursery should be closed, 
that currents of air may be avoided. The ventilation by means of an open 
fire is the most efficient. 

The furniture of the nursery should be as simple as possible, heavy 
hangings should be positively forbidden, and upholstered furniture used 
only to a small extent. Floors covered by large rugs are much more clean- 
ly than carpets, and hence are to be preferred. 

The child, whenever it is possible, should have a separate bed ; and 
so should the newly born infant, in order to prevent the danger of over- 
lying by the mother, which among the lower classes is a frequent cause of 
death, and also to avoid the danger of too frequent night nursing, which is 
injurious alike to mother and child. Separate beds for older children will 
prevent the spread of many forms of infection from the diseased child to 
the healthy. The cradle for infants should be one which does not rock, in 
order that this unnecessary and vicious practice should not be carried on. 
The mattress should be of hair and quite firm. The pillow should be 
small ; in the summer, hair pillows are an advantage but not a neces- 
sity. The position of the child during sleep should be changed from 
time to time from one side to the other and then to the back. Atten- 
tion to all these details should not be beneath the physician's notice, since 
the violation of these plain rules of hygiene is at the bottom of many 
of the milder disorders and even of some of the more serious diseases seen 
in infancy. 

The Nurse. — The nurse of a young child should be healthy, young 
or in middle life, free from tubercular or syphilitic taint, and from ca- 
tarrhal affections of the nose and throat. She should be neat in habit, 
of quiet disposition, and, most of all, she should be a person of intelli- 
gence. 

The Amount of Air Space required by Infants. — The nursery should 
always be as large a room as possible. One of the reasons why young 
infants do so badly in institutions is because of overcrowding. In a 
well-ventilated ward there should be allowed to each infant at least 1,000 
cubic feet for the best results. Children over two years old are not so 
sensitive to their surroundings, and may thrive in wards where only 700 
or 800 cubic feet are allowed to each child. 



THE CARE OF PREMATURE AND DELICATE INFANTS. 

Infants born before term, and some exceedingly delicate ones which are 
born at full term, require very special and particular care. The vitality is 
so feeble in these children that if they are handled in the ordinary way 
they survive at most but a few weeks. The symptom which indicates that 
such special care is necessary is most of all the weight of the child. Either 
congenital feebleness or prematurity may be assumed in most of the chil- 



THE CARE OF PREMATURE AND DELICATE INFANTS. H 

dren weighing less than four pounds. This is certainly true of those 
weighing less than three pounds ; also if the length of the body is less than 
nineteen inches. In these children all the organs are likely to be imper- 
fectly developed and they are not ready for their work. Especially is this 
true of the lungs and of the organs of digestion. 

The clinical picture presented by these cases is quite characteristic. 
The body is limp ; the skin very soft and delicate and almost transparent ; 
the cry, a low feeble whine not unlike the mew of a kitten ; the respira- 
tory movements, extremely irregular, sometimes scarcely perceptible for 
several seconds ; the movements of the extremities infrequent and never 
vigorous. The general appearance is one of torpor. The muscles of the 
mouth and cheek and tongue may lack the requisite force for sucking, 
so that this is practically impossible, and even deglutition is slow, diffi- 
cult, and prolonged. Unless very carefully protected the temperature of 
the body quickly falls to a subnormal point, and it is difficult to maintain 
the normal body heat. These symptoms vary much in degree according 
as the infants are born at six and a half, seven months, or only shortly be- 
fore term. 

In the management of these cases there are two problems to be solved : 
the first to maintain the animal heat, the second to nourish the infant. 
Difficult as it always is to rear a premature infant, these difficulties are 
much increased in cases where proper means are not adopted immediately 
after birth. The loss which these children sustain during the first few 
days is in very many cases so great that subsequent measures, however 
well carried out, are futile. The heat-producing power is so feeble that 
the body temperature quickly falls below normal unless artificial heat is 
constantly used. The effect of cold upon these delicate infants is very 
serious, and not only growth but even life depends upon maintaining the 
body temperature steadily and uniformly. Their extreme susceptibility 
is something which it is difficult for one to appreciate who has not had 
experience in these cases. 

One of the simplest means of maintaining the temperature is to oil 
the skin and then roll the entire body in cotton batting, no clothing ex- 
cepting the diaper being used. The body should then be wrapped in 
two or three blankets and surrounded by bottles or rubber bags con- 
taining hot water. These means are usually sufficient in infants of three 
and a half pounds or over, but in those much under this weight this 
is not enough. Where cotton is used it should be changed only once in 
two or three days, excepting about the buttocks. If absorbent cotton 
be used in this region instead of cotton batting, the napkin may be 
dispensed with altogether. This cotton may be changed as often as it is 
soiled by the discharges. These children should not be bathed, but the 
skin should be kept in a healthy condition by rubbing with sweet oil once 
in two or three days. 



12 



HYGIENE AND GENERAL CARE OF INFANTS. 



Incubators. — In the case of infants born in the seventh month, and 
in some even later than this, the animal heat which can be maintained 
by the means described is inadequate to the child's needs. For such 
cases an incubator must be employed. The following statistics are pub- 
lished by Tarnier, showing the results obtained in his hospital in Paris 
during five years with the incubator and for the five years before its in- 
troduction : 



A«E. 


Percentage saved 
with incubator. 


Percentage saved 
without incubator. 


Infants born at 6 months 


16-0 
36-6 

49-8 
77-0 
88-8 
96-0 




" " 6i " 


21-5 


" "7 " 


39-0 


« " 7-4- " 


54-0 


" "8 " 


78-0 


« " 8£ ' k 


88-0 







The essential thing to be secured in an incubator is a uniform temper- 
ature, which in the most delicate infants should be maintained at 96° to 
98° F. In those a little more robust, from 85° to 95°. The air must at 
the same time be moistened, and there must be sufficient ventilation to 
keep it pure. 

A modification of Tarnier's incubator is shown in the accompanying 
illustrations. (Figs. 1 and 2). This consists of a wooden box thirty 




'i'l!" 1 - i"iiiiiiiii!iimi]iiiii-ii[| 

Fig. 1. — Incubator. 



inches long, fifteen inches wide, and twenty inches high. It is composed 
of an outer and inner box, each one half inch in thickness, with an air 
chamber one fourth of an inch in thickness separating them, excepting 



INCUBATORS. 



13 



at the bottom, which is solid. It may be made solid throughout. The 
temperature is maintained by a large tank of warm water four inches in 
height which completely fills the bottom of the incubator. This is so 
arranged that it can be emptied and filled without opening the box. Con- 




Fig. 2. — Section of incubator, showing construction. 

nected with one end of the tank is a loop of brass 
pipe. To this is attached a funnel for filling and a 
faucet for emptying the tank. Beneath this pipe the heat is applied. 
The tank, which holds five or six gallons, is filled with hot water, and the 
heat is then maintained by the flame of a Bunsen burner or an alcohol 
lamp. The lamp stands upon a hanging shelf made of tin. Fresh air is 
admitted at four openings, three inches in diameter, two being on each 
side. A slide is so arranged that one or all of these can be opened as de- 
sired. The air passes over the upper surface of the tank, is moistened by 
a wet sponge, and finds its exit at the top. A thermometer is placed, on 
the inside of the box just over the bed, so that the exact temperature 
can be seen. A portion of the cover consists of a sliding plate of glass, 
through which the child can be observed, and by partly opening which 
it can be fed. The infant lies upon a bed of cotton, in some cases naked, 
in others enveloped in the cotton. The discharges are received in the 
cotton upon which it lies. The infant is kept clean by the use of oil 
and cotton. It is not to be removed for feeding, since the food is usually 
given by gavage, and this can be done by sliding the cover. Every day 
the child should be taken out long enough to allow thorough cleansing 
and airing of the incubator, introduction of fresh cotton, etc. 

This apparatus, which was devised by Dr. E. J. Sherow and myself, 
can be made by any carpenter and tinsmith at a very moderate expense. 
The only difficulty is with the ventilation. This is quite easy provided 
the temperature of the room in which the incubator stands is not over 



14 HYGIENE AND GENERAL CARE OF INFANTS. 

65° or 68° F., but much more difficult when it is at 75° or over, as in 
warm weather. At such times all the doors for the entrance of air should 
be opened to the full extent and the glass cover opened from one half to 
two inches. 

Kotch,* of Boston, has devised a very elaborate incubator which con- 
tains a very perfect heating and ventilating apparatus and also scales, so 
that the weight of the infant can be ascertained every day without remov- 
ing it. This apparatus, which is without doubt the best that has been 
devised, is made of metal, principally of copper. The only objection is 
its cost. The apparatus which I have described above is one with which 
excellent results can be obtained, but it requires a little more care and 
attention. The essential thing in all cases is a constant temperature and 
free ventilation. 

The child is kept in the incubator until it is nearly full term, or has 
become, judging by its activity, sufficiently strong to withstand the varia- 
tions in temperature of an ordinary room. Before it is taken out perma- 
nently the temperature of the incubator should be gradually lowered by 
opening the cover more and more until it is only a little higher than' the 
temperature of the room, clothing being of course added at the same 
time. 

The feeding of the premature infant is not less important than the 
use of the incubator. Very few infants before eight months can be de- 
pended upon to take a proper amount of food from the breast or bottle. 
Forced feeding by means of gavage is indispensable in order to save these 
very young and very delicate children. This method of feeding is de- 
scribed elsewhere. The amount of food will depend upon the age of the 
child. At seven months one half ounce may be given every hour and a 
half, and at eight months three fourths of an ounce at the same interval. 
The food employed should if possible be breast milk. If artificially fed 
the feeding should be carried on as described in the chapter on the feed- 
ing of delicate children during the first year. With careful attention to 
details and intelligent co-operation on the part of a good nurse very many 
of these cases may be saved that otherwise would be absolutely hopeless. 

The incubator thus far has not been so much employed in America as 
in Europe, where the most gratifying results have followed its use, par- 
ticularly in Paris, St. Petersburg, and Moscow. 

* Archives of Pediatrics, August, 1893. 



CHAPTER II. 
GROWTH AND DEVELOPMENT OF TEE BODY. 

Observations upon growth and development are of the utmost im- 
portance during infancy and childhood. Only by this means are very 
many diseases detected in their incipiency. Early recognition carries 
with it in most cases the possibility of checking such pathological pro- 
cesses, as, if allowed to go on, may affect the health not only in infancy 
but even throughout life. 

By familiarity with what is normal, detection of the abnormal soon 
becomes easy. Investigation in regard to these subjects should be made a 
part of the physical examination of every child. 

WEIGHT. 

The weight of the infant is the best means we have to measure its 
nutrition. It is as valuable a guide to the physician in infant feeding as 
is the temperature in a case of continued fever. Although the weight is 
not to be taken as the only guide to the child's condition, it is of such 




Fig. 3. Fig. 4. 

importance that we cannot afford to dispense with it during the first two 
years. It is a great advantage to keep up regular observations during 
childhood. 

Weekly weighings should be made for the first six months, bi-weekly 
for the rest of the first year, and monthly during the second year. Deli- 
cate children should be weighed even more frequently. Satisfactory scales 
of moderate price for domestic use are those known in the shops as the 
"Universal Family Scales." (Fig. 3). These weigh up to twenty-four 

15 



16 



GROWTH AND DEVELOPMENT. 



pounds and indicate ounces. For hospital use and for very fine observa- 
tions more accurate scales are needed. In Fig. 4 are shown the scales I 
employ ; they weigh up to sixty-one pounds and indicate half ounces.* 

Weight at Birth. — The following figures are taken consecutively in 
nearly equal proportion from the records of the Nursery and Child's 
Hospital, the Sloane Maternity, and the New York Infant Asylum, and 
include only full-term children : 

Average weight of 568 females 7- 16 lbs. (3,260 grammes). 

590 males 7'55 " (3,400 .." ). 



1,158 infants 7-35 " (3,330 



)• 



Weight Curve during the First Few Weeks. — The accompanying 
chart represents the variations in weight for the first twenty days. These 
observations were made upon one hundred healthy, nursing infants, fifty 

males and fifty fe- 
males, at the Nursery 
and Child's Hospi- 
tal. The children 
were weighed daily 
during the period 
of observation. The 
average weight at 
birth was 7-1 pounds. 
The curve shows a 
very marked loss of 
weight on the first, 
day and a slight loss 
on the second day, 
the lowest point be- 
ing touched at the 
beginning of the 
third day ; but from 
this time there was 
a steady gain. The 
average initial loss 
in these cases was 



DAILY WEIGHT CHART. 
Name,....- Bate of Birth, 189 


Gms. 


Lbs. 


l 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


4420 
4310 
4200 
4080 
3970 
3850 
3740 
3030 
3510 
3400 
3290 
3180 
3060 
2940 
2830 
2720 
2610 
2490 
2380 


9%" 

9)4 

VA 
9 

S% 

8 

1 X A 

7 

VA 

6 

5% 

VA 








- 










































































































































































































































































































































































































































































































































































— 








































































































































































































































_ 







Fig. 5. — Weight curve of the first twenty days. 



ten ounces, being in each sex exactly eleven per cent of the body weight. 
In eight hundred and thirty-five cases, however, including those above 
mentioned, the average loss was nine and a half ounces. The loss of the 
first days is chiefly due to the discharge of the meconium and urine, but is 
in part from the excess of tissue waste over the nutriment derived from 
the breasts. After the third day, coincident with an abundant secretion 



* These are made by the Howe Scale Company. 



WEIGHT CURVE OF THE FIRST YEAR. 17 

of milk, there is a steady, daily increase in weight. If the milk is very 
scanty or is wanting altogether, the loss in weight continues. 

The birth-weight of nursing children who thrive normally is regained 
on the average on the tenth day. The most frequent deviation from the 
normal curve consists in a continued loss or stationary weight after the 
third day. This may be due to acute illness, such as bronchitis, diarrhoea, 
pyaemia, or hemorrhage, but in the majority of cases there is a disturbance 
of nutrition from improper or insufficient food. This is quite as likely to 
be the case in nursing infants as in those who are artificially fed. Under 
these circumstances the loss may continue indefinitely, and it may be slow 
or rapid according to the character of the nursing or feeding. 

The weight curve in strong infants who are artificially fed in the 
proper way from the beginning, follows in some cases the same course as 
in nursing infants. There are many infants who, though properly fed, 
gain very little or not at all for two or three weeks, often not regaining 
the birth-weight until the end of the third or fourth week. Such infants 
should be closely watched and weighed twice a week, and if the weight 
is stationary, one should not be too ready to make a change in the food. 
A continued loss in weight, however, is an invariable indication that this 
should be done. It should be expected that most artificially fed infants 
will be slower in getting started, but in my experience their subsequent 
gain under favourable circumstances has been quite as regular and as 
rapid as that of average, breast-fed children. 

There are cases in which an excessive loss of weight during the first 
three or four days is associated with an elevation of temperature, but 
without any other evident signs of disease. Both the fever and the rapid 
loss in weight are to be looked upon as due to the same cause — inani- 
tion. This will be more fully considered in the chapter devoted to that 
subject. 

Excessive loss in weight during the first few days from any cause 
whatsoever, seriously handicaps an infant during the first weeks of its 
life. The great importance of this has not been sufficiently appreciated. 
Loss in weight after the second day is an indication for food in addition 
to that derived from the breast. 

Weight Curve of the First Year. — The curve of the accompanying 
chart is made up from complete weight charts of one hundred healthy 
nursing infants who were thriving and weighed every week, and the in- 
complete charts of about three hundred others. There are represented 
in round numbers about ten thousand observations on children under 
one year. The period of most rapid increase is during the first three 
months. It is slowest from the sixth to the ninth month. This curve is 
not to be regarded as a normal line, like the normal line of the tempera- 
ture chart, but as an average line. An infant who is at birth a pound 
above the average may keep this distance above the line for the whole 



18 



GROWTH AND DEVELOPMENT. 



year ; another weighing one pound less than the average may be as far 
below it. G-irls throughout the year are on the average half a pound 
lighter than boys. No single child exactly follows the line all the way, 
but it is surprising to see how close to it a very large number of the cases 
come. 

In artificially-fed infants — provided the feeding is properly done — the 
curve does not differ essentially from that of breast-fed infants, excepting 



WEIGHT CHART. 
Name, Date of Birth, i8g 


£ 


-O 

_l 


MONTH OF AGE. 


123456 78 9 10 11 12 


10890 
10430 
9980 
9530 
9070 
8620 
81G0 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


24 
23 

22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
G 
5 


















































































































































































































































































- 
































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































s 


s 


























































































/ 






















































































































































































/ 
























































































































































































































































































































































































































































































































































































































































































































































































































































































































































/ 

















































































































































































































































































































































































































































































































































































































































































Fig. 6. — The weight curve of the first year. 

in the slower gain of the first one or two months, although this difference 
is usually made up before the sixth month is reached. 

At the end of the first year the average child weighs nearly three times 
as much as at birth. Perfect health during the first year is consistent 
only with a steady gain in weight. A child may not always gain rapidly, 
but it should gain steadily, and if it does not, something is wrong. All 
the conditions surrounding the infant should be investigated, but espe- 
cially the food. One should not be satisfied unless the average weekly 
gain during the first six months is at least four ounces. In the second 
six months it may be slightly less. It may be taken as a rule that a 
child who gains regularly in weight is thriving ; an exception must, how- 
ever, be made in the case of some infants who are fed chiefly upon carbo- 
hydrate foods. 



THE WEIGHT OF OLDER CHILDREN. 



19 



Weight from the Second to the Fifth Year. — Comparatively few obser- 
vations have been published upon the weight during this period. From 
three hundred and seventy-two personal observations it appears that the 
gain is about six pounds during the second year, about four and a half 
during the third year, and about four pounds during the fourth year : the 
actual weights are given in the large table (page 20). During this period 
the gain is rarely steady even in the second year. With most children it 
is slowest or the weight is stationary in the summer months, while the 
most rapid increase is usually seen in autumn. Throughout this period 
the girls gain in about the same ratio as boys, but remain on the average 
nearly one pound lighter. During almost every illness, no matter of what 
character, the gain in weight ceases, and usually there is a loss, the rapid- 
ity and extent of which are somewhat proportionate to the severity of the 
attack ; but it is always much more rapid in diseases of the digestive tract 
than in any other form of illness. 

Weight of Older Children. — The weights given in the table of children 
from five to fourteen years are from Bowditch. Observations were made 
upon children of American parentage in the public schools of Boston — 
npon 4,327 boys and 3,681 girls.* It is to be remembered that these 
weights include the ordinary clothing, while those below five years are 
without clothing, f 

The slowest gain is from the fifth to the eighth year, when it is about 
four pounds a year. From the eighth to the eleventh year it rises to about 
six pounds a year. Up to the eleventh year the two sexes gain in about 
the same ratio. From the eleventh to the thirteenth year the girls gain 



* W. T. Porter has published (1894) observations made upon 14,744 children of Amer- 
ican parentage in the public schools of St, Louis. His figures show quite a variation 
from those of Bowditch, and are as follows : 





BOYS 1 WEIGHT. 


GIRLS 1 WEIGHT. 


Age. 


Kilos. 


Pounds. 


Kilos. 


Pounds. 


6 vears 


19-66 
21-67 
23-91 
26-08 
28-49 
31-26 
33 45 
35-96 
40-34 
47-25 
52-10 


43-2 
47-7 
52-6 
57-4 
62-7 
68-8 
73-6 
79-1 
88-7 
103-9 
114-6 


18-76 
20-82 
22-71 
25-07 
27-43 
29-93 
33-17 
38-29 
43-12 
46-90 
50-06 


41-3 


7 " 


45-8 


8 " 


50-0 


9 " 


55-1 


10 " 


60-3 


11 " 


65-8 


12 " 


73-0 


13 " 


84-2 


14 " 


94-9 


15 " 


103-2 


16 " 


110-1 







f The average weight of the ordinary house clothing of school children, according 
to Bowditch, is at five years 2*8 pounds for both sexes ; at seven years, 3-5 for both 
sexes ; at ten years, 5*7 pounds for boys and 4-5 pounds for girls ; at thirteen years, 7'4 
pounds for boys and 5-6 pounds for girls ; at sixteen years, 9-7 pounds for boys and 8'1 
pounds for girls. This must be deducted from weights given to obtain the net weight. 



20 



GROWTH AND DEVELOPMENT. 



much more rapidly, passing the boys for the first time and maintaining 
this lead until the fifteenth year, when again the boys pass them. 

Table showing Weight, Height, and Circumference of the Head and 
Chest from Birth to the Sixteenth Year.* 



Age. 



Birth 

6 months 

12 months 

18 months. . . . 

2 years 

3 years 

4 years 

5 years 

6 years 

7. years 

8 years 

9 years 

10 years 

11 years.. 

12 years 

13 years 

14 years 

15 years 

16 years 



Sex. 



Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 

Boys. 

Girls. 



Pounds. Kilos 



7 
7 

16 

15 

20 

19 

22 
22 



25 

31 

30 

35 

34 

41 



45 

43 

49 

48 

54 

52 

60 

57 

66 



72 

70 

79 

81 

88 
91 

99 

100 

110 

108 

123 

113 



3 43 

3 26 



Inches. Cm 



20 

20 

25 

25 

29 

28 

30 

29 

32 

32 

35 

35 



41 

41 

44 

43 

46 

45 

48 
48 

50 

49 

52 

51 

54 

53 

55 

57 

58 
58 

61 

60 

63 

61 

65 

61 



52 

52- 

64 

63- 

73 

73- 

76- 

75- 

82' 
82- 

89- 
89- 

96 

96- 

106- 

105' 

112 

110- 

117 

116- 

122 

122' 

127 

126- 

132 

131 

137 

136- 

141 

145- 

147 

149- 

155 

153- 

159 

155- 

166 

156- 



Inches. Cm 



5 

•2 


13. 

13- 


•8 
•6 


16 

16- 


•8 

•2 


18- 

17- 


•3 

•6 


18- 

18- 


•8 
•8 


19- 

18- 


1 

•1 


20 

19- 


•7 
•7 


20 

20-. 




•3 


21- 

21-< 




9 


23 

22-( 


•4 

•7 


23- 

23 -J 


•3 

•1 


24 

23-( 


•2 

•0 


25 

24-, 


6 

•5 


25- 

24- 


•2 

•6 


26 

25-J 


•7 
•2 


27- 

26-1 


•7 
•2 


27- 

28-( 


1 

•2 


28- 
29-5 


•9 

•9 


30 

30-1 


•5 

•7 


31 

30-! 



Inches. Cm 



139 

13-5 

17 

16-6 

180 

17-6 

18 5 

18-0 

189 

18-6 

19 3 

19-0 

19 7 

19-5 

20 5 

20-2 



210 

20-7 



21 8 

21-5 



35 5 

34-5 

435 

42-2 

45 9 

44-6 

471 

45-9 

48-2 
47-2 

490 

48.4 

50.3 

49.6 

52.2 

51.3 



53 5 

52-8 



55 5 

54-8 



* The recently published observations of Boas (Science, April 12, 1895) upon 4,319 
children over six years old show that first born exceed later children both in height 
and weight. 



GROWTH OF THE EXTREMITIES. 21 

HEIGHT. 

The figures showing the height at different ages are given in the fore- 
going table. The measurements of infants at birth are taken in about 
equal numbers from the records of the New York Infant Asylum and 
the Sloane Maternity Hospital. They were made upon full-term infants. 

Average length of 231 males 20*61 inches (52*5 cm.) ; 

211 females 20-47 ' ; (52*2 "); 

443 infants 20-54 " (52-35"). 

The most rapid gain in length is in the first year. During this period 
the child grows on an average a little over eight inches (21 cm.). This 
gain is usually, but not always, proportionate to the increase in weight. 
During ^the second year the average increase is three and a half inches (9 
cm.). From this time on the rate of increase is quite uniform in both 
sexes until the eleventh year, it being between two and three inches a 
year. 

After the eleventh year in girls and the twelfth in boys the growth is 
much more rapid. In height the girls exceed the boys at the twelfth and 
thirteenth years for the only time in their growth. 

In the figures given in the preceding table those of five years and over 
are taken from Bowditch,* the observations being made upon the same 
children as those whose weights were taken. The observations from six 
months to four years inclusive are from original sources, and are drawn 
from about five hundred cases. The height much more than the weight 
of children is modified by hereditary influences. 

Rachitic children during infancy and early childhood are, as a rule, 
shorter than others. I have frequently measured such children during 
the third year who were six inches below the average for that age. The 
effect of malnutrition upon the length of the body is much less than on 
the weight. 

GROWTH OF THE EXTREMITIES AS COMPARED WITH THE TRUNK. 

At birth the trunk is relatively long and the extremities short. Sub- 
sequently the growth of the extremities is much more rapid than that of 
the trunk. Thus I have found at birth the length of the lower ex- 
tremities (measuring from the anterior superior spine of the ilium to the 
sole of the foot) to be forty-three per cent of the length of the body ; at 
five years, fifty-four per cent, and at sixteen years sixty per cent. The 
above figures are from one hundred and fifty observations, which, although 
not numerous enough for exact percentages, are still sufficient to give a 

* According to the observations of Porter, the St. Louis children reach a given 
height on the average about one year later than Boston school children. 



22 GROWTH AND DEVELOPMENT. 

very good idea of the general relation of the length of the extremities to 
that of the body as a whole. 

THE HEAD. 

Circumference. — The average circumference of the head at birth in 
four hundred and forty-six full-term infants taken in about equal num- 
bers from the Sloane Maternity Hospital and New York Infant Asylum 
was as follows : 

Average circumference of the head, 231 males. . 13-90 inches (35*5 cm.); 

" 215 females. 13*52 " (34 -5 " ); 

Total 446 infants. 13-71 " (35-0 " ). 

The occipito-frontal measurement has been the one taken. 

The growth of the head is most rapid during the first year, the in- 
crease being about four inches (10 cm.). During the second year the in- 
crease is about one inch (2*5 cm.). From the second to the fifth year the 
growth is slower, being only about one and a half inches (4 cm.) for the 
three years. After the fifth year the increase in the circumference of the 
head is very slow, as shown by the preceding table. 

Closure of the Sutures. — The main sutures of the cranium are not 
commonly ossified before the end of the sixth month, and very frequently 
some mobility may be detected at the end of the ninth month. Distinct 
separation of the cranial bones after birth is abnormal. It is most fre- 
quently seen in premature and in syphilitic infants, but rarely in this 
country as the result of congenital rickets. 

Closure of the fontanels. — The posterior fontanel is usually obliterated 
by the end of the second month. The anterior fontanel under normal 
conditions closes on an average at about the eighteenth month. The 
usual variations are between the fourteenth and the twenty-second months. 
At the end of the first year the fontanel should be about one inch in 
diameter. An open fontanel at the end of the second year may always 
be considered abnormal. Kickets is the usual explanation. 

The closure of the fontanel is not always early in well-nourished chil- 
dren, nor is it always delayed in those suffering from malnutrition. It 
often happens that in a child with marked evidences of malnutrition the 
fontanel at ten or twelve months is nearly or quite closed and the sutures 
firmly ossified. In such children the head is usually small, and the early 
closure is partly due to the slow growth of the brain. On the other hand, 
it is sometimes the case that in stout, well-nourished children the fontanel 
may remain open until nearly the end of the second year, although the 
child presents every evidence of perfect nutrition and no signs of rickets. 
This may be due to the fact that the brain has grown with more than 
usual rapidity. When, however, there is any great disproportion between 
the size of the head and the development of the rest of the body, or when 



SHAPE OF THE HEAD. 23 

the circumference of the head exceeds very much the figures given in the 
table above, either rickets or hydrocephalus should be suspected. 

Shape of the Head. — The deformity which results from compression 
during labour usually disappears by the end of the first month. During 
the first year the head often becomes flattened at the occiput in conse- 
quence of the child's lying too much upon the back. This is easily 
remedied by changing its position. A slight obliquity of the head may 




Fig. 7. — Premature ossification of the sagittal suture. Death at six weeks. 

be produced by the child's being habitually held in one position, as iu 
some cases where it is nursed only at one breast, or where it is always 
laid upon the same side during sleep. 

The other abnormities in the shape of the head are chiefly due to 
rickets and hydrocephalus, more rarely to congenital malformations of 
the brain. They will be considered in the chapter devoted to these topics. 

Premature ossification of the sutures of the cranium occasionally gives 
rise to a very striking deformity of the head. I have recently seen two 
cases of such deformity from premature ossification of the sagittal suture. 
The heads in both cases were very narrow and long in the antero-poste- 
rior diameter. The forehead was narrow, prominent, and slightly pro- 



24 GROWTH AND DEVELOPMENT. 

jecting. The accompanying illustration shows the skull of one of these 
cases. There is a complete obliteration of the sagittal suture. In this 
case there was a wide separation of the sutures at the junction of the 
parietal and temporal bones. (See Fig. 7.) 

THE CHEST. 

The figures showing the circumference of the chest at the different 
periods of childhood are given on page 20. The measurements up to 
and including five years are from original sources, those from the sixth 
to the sixteenth are taken from Porter, and are drawn from observations 
on 31,371 school children. The measurement of the chest is that taken 
midway between full inspiration and expiration, and at the level of the 
nipples. 

In the newly born child the antero-posterior and the transverse diame- 
ters of the chest are nearly the same. As age advances, the transverse 
diameter increases very much more rapidly, so that the outline of the 
chest gradually assumes an elliptical shape, which it maintains during 
childhood. 

At birth, the circumference of the chest is about one half inch less 
than that of the head, but throughout infancy the two measurements 
are nearly the same. It is not until the third year that the circum- 
ference of the chest exceeds that of the head. According to Uffel- 
mann, the circumference of the head and the chest are the same until 
the twenty-first month in a robust child, and until two and a half years 
in an average child. If at three years the chest continues smaller than 
the head, the child is likely to be a weak one. If the chest is below 
the average at birth, it is likely to remain so throughout infancy. 
The chest measurement in infants is always much modified by the 
amount of fat ; but, after making due allowance for this, a large chest 
always indicates a robust child and a small chest a delicate one. If at 
any age the circumference of the child's chest is found to be below the 
average, measures should be taken, by gymnastics and otherwise, to 
develop it. 

Deformities of the thorax result chiefly from rickets, sometimes from 
empyema, emphysema, and cardiac disease ; in older children, from lateral 
curvature of the spine, or from Pott's disease. 

THE ABDOMEN. 

Throughout infancy the circumference of the abdomen is, as a rule, 
about the same as that of the chest. At the end of the second year 
the measurements of the head, chest, and abdomen are very often identi- 
cal ; after this time the chest measurement increases much more rapidly 
than the other two. Marked enlargement of the abdomen is seen in 



( 



DEVELOPMENT OF THE SPECIAL SENSES. 25 

many varieties of chronic intestinal disorders. It is, however, most 
marked in the tympanites which so constantly accompanies rickets. 

MUSCULAR DEVELOPMENT. 

The first voluntary movements are usually in the fourth month, when 
the infant deliberately attempts to grasp some object placed before it. 
During the fourth month, as a rule, the head can be held erect when the 
trunk is supported. In many infants this is possible in the early part 
of the third month. At seven months a healthy child is usually able to 
sit erect and support the trunk for several minutes. 

In the ninth or tenth month are usually seen the first attempts to bear 
the weight upon the feet. At ten or eleven months a child stands with 
slight assistance. The first attempts at walking are commonly seen in 
the twelfth or thirteenth month. The average age at which children 
walk freely alone has been, in my experience, the fourteenth or fifteenth 
month. Quite wide variations are seen in healthy children. Very much 
depends upon the surroundings. I have known infants to walk at ten 
months and many others not until seventeen or eighteen months, although 
showing no evidences of disease, and although their development had not 
been retarded by previous illness. A very marked difference is seen in 
different families of children with respect to the time of walking. 

The physician is often consulted because of backward muscular devel- 
opment, most frequently because the child is late in walking. General 
malnutrition, or any other severe or prolonged illness, may postpone for 
several months this or any of the other functions mentioned. When 
there is no such explanation of the backwardness, a child who does not 
hold up its head, sit alone, or make efforts to stand or walk at the proper 
time, should be submitted to a careful examination for a cerebral or spinal 
paralysis, but especially for rickets which is the most frequent explanation 
of the symptoms. 

Contrivances for teaching infants to walk are unnecessary, and their 
effect may even be injurious. An infant should be allowed the greatest 
possible freedom in the use of its limbs. It should not be restrained 
from walking when inclined to do so, nor continually urged to walk when 
no voluntary attempts are made. Nothing short of mechanical restraint 
will prevent a healthy child from walking or standing when it is strong 
enough to do so. 

DEVELOPMENT OF THE SPECIAL SENSES.* 

Sight. — The newly born infant avoids the light. Its pupils contract 
in a light room, and if a bright light is brought before the eyes they 

* For many of the facts in this paragraph I am indebted to Preyer's The Senses 
and the Will, American edition, 1888, D. Appleton & Co. 
4 



26 GROWTH AND DEVELOPMENT. 

close. During the first few weeks the infant indicates by every sign that 
excessive light is unpleasant. As early as the sixth day the eyes will 
sometimes follow a light in the room, and the child may even turn the 
head for this purpose. The muscles of the eyes of the newly born infant 
act irregularly and not in harmony. Co-ordinate action for general pur- 
poses is not established until about the end of the third month. Even 
after this time inco-ordinate action is occasionally seen. The eyelids also 
move irregularly, and are often partly separated during sleep. The cornea 
is but slightly sensitive during the first weeks. In Preyer's child it was 
not until the third month that the lids closed when the water in the bath 
touched the lashes or the cornea. The recognition of objects seen is usu- 
ally evident in the sixth month. 

It is important that the room in which the newly born child is placed 
should be darkened, and that for the first few weeks the eyes should be 
protected against strong light. 

Hearing. — For the first twenty-four hours after birth infants are 
deaf. This deafness sometimes persists for several days. It is believed 
to be due to absence of air from the middle ear and to swelling of the 
mucous membrane which lines the tympanum. With the movements of 
respiration, air gradually finds its way into the middle ear, and the swell- 
ing subsides during the first few days. After this the hearing gradually 
improves, and during the early months of life it is very acute. The child 
starts at the slamming of a door, and even moderately loud noises will 
waken it from sleep. By the end of the second month it will sometimes 
turn its head in the direction from which the sound comes, and by the 
end of the third month this will usually be done. Derame found, in 
observations upon one hundred and fifty infants, that the voices of parents 
were recognised on an average at three and a half months. 

Not only are the ears unusually sensitive to sound in infancy, but 
the impression produced upon the brain is often marked — very loud 
sounds causing great fright, and sometimes even, it is reported, convul- 
sions. 

Touch. — Tactile sensibility is present at birth, but is not highly devel- 
oped except in the lips and tongue, where it is very acute for the obvious 
necessity of sucking. After the third month it is fairly acute over the 
surface of the body generally. Two especially sensitive areas, according 
to Preyer, are the forehead and external auditory meatus. 

Sensibility to painful impressions is present in early infancy, but very 
dull as compared with later childhood. 

Temperature is also distinguished. This recognition is especially 
acute in the tongue. A young infant is often seen to refuse to take 
the bottle because the milk is only a few degrees too cold or too 
warm. 

The localization of sensory impressions comes later, probably not much 



DENTITION. 27 

before the middle of the sixth month, and is very imperfect throughout 
the first year. 

Taste. — This is highly developed, even from birth. According to the 
experiments of Kussmaul, the ability to distinguish sweet, sour and bit- 
ter, exists in the newly born child — sweet exciting sucking movements, 
and bitter, grimaces. A young infant detects with surprising accuracy 
the slightest variation in the taste of its food, and the smallest difference 
is often enough to cause it to refuse its bottle altogether. Sweet sub- 
stances are always easily administered, and in combination with sirups 
even very bitter substances can be given ; but to aromatic powders and 
elixirs it usually objects. 

Smell. — Observations upon the sense of smell in newly born infants 
are few and not altogether conclusive. Kroner's experiments appear to 
show that smell is present in the newly born. It has been noted to be 
especially acute in infants bom blind. The sense of smell is developed 
much later than the other senses. Detection of fine differences in odours 
is not acquired until quite late in childhood. 

SPEECH. 

There is a very wide variation in children with reference to the time 
of development of the function of speech. Girls, as a rule, talk from two 
to four months earlier than boys. Towards the end of the first year the 
average child begins with the words " papa," " mamma." By the end of 
the second year it is able to put words together in short sentences of two 
or three words. Progress in speech from this time is very rapid, each 
month showing great improvement. Names of persons are commonly first 
acquired, then the names of objects. Next to this the verbs are learned, 
and then adverbs and adjectives. Conjunctions, prepositions, and articles 
follow in order, and last of all the personal pronouns. 

If a child of two years makes no attempt to speak, some mental defect 
may usually be inferred. 

DENTITION. 

The teeth are enclosed at birth in dental sacs which are situated in the 
gums. Above, they are covered by the submucous connective tissue and 
the mucous membrane ; below, the dental sacs rest in depressions in the 
alveolar process of the jaw. The tooth grows in length mainly as the 
result of the calcification of its roots, and being thus fixed below, it pushes 
upward towards the mucous membrane. This growth undoubtedly goes 
on steadily from birth until the tooth pierces the gum. 

The deciduous or milk teeth are twenty in number. The time at 
which they appear is subject to considerable variation even under normal 
conditions. The following is the order and the average time of appearance 
of the different teeth : 



28 GROWTH AND DEVELOPMENT. 

(1) Two lower central incisors 6 to 9 months. 

(2) Four upper incisors 8 " 12 " 

(3) Two lower lateral incisors and four anterior molars. 12 " 15 " 

(4) Four canines 18 " 24 " 

(5) Four posterior molars . 24 " 30 " 

At 1 year a child should have 6 teeth. 

At H " " " " 12 " 

At 2 years " " " 16 " 

At 2* " « " " 20 " 

Quite wide variations on both sides of the average are common, and 
are not always easy of explanation. In many cases it seems to be a family 
idiosyncrasy, since in the different members of a family the teeth are 
apt to appear at about the same time. I know one family in which no 
less than three members of three successive generations were born with 
teeth, and in most of the other members the first teeth appeared in the 
third or fourth month. The order in which the teeth appear is much 
more regular than the time of their appearance. The order given above 
corresponds with that stated by most observers, although some writers 
have made different statements, placing the lower before the upper lateral 
incisors. 

The teeth may pierce the gum without any local manifestations. Very 
frequently, however, just before a tooth comes through there is noticed a 
moderate swelling and redness of the mucous membrane of the gum over- 
lying it, and to a slight degree this may affect the general mucous mem- 
brane of the mouth. This condition may be accompanied by a little fret- 
fulness and increased salivation, or both of these may be entirely wanting. 
These symptoms usually disappear when the tooth has pierced the gum. 
The symptoms of difficult dentition will be discussed in connection with 
Diseases of the Mouth. 

Infants may be born with teeth ; this is, however, an exceedingly rare 
occurrence. It is almost invariably one of the lower central incisors that 
is present. In case this interferes with nursing, or if it is very loosely 
attached to the gum, it should be extracted, but under other circumstances 
it should be allowed to remain, since, if it is removed, a second tooth is 
not likely to appear in its place in the first set. It is not at all uncommon 
for the first teeth to appear in the fourth month. Such teeth, in my 
experience, do not usually differ in character from those appearing later, 
unless they are in children who are syphilitic. Syphilitic children are 
rather prone to early dentition, and under such circumstances rapid and 
early decay is likely to take place. Nursing infants are, as a rule, a little 
earlier in their dentition than those artificially fed. 

Delayed dentition is much more frequently due to rickets than to all 
other causes combined. It is to be remembered, however, that the first 
teeth may not appear until the tenth month in healthy, well-nourished 
children and in those who present no signs whatever of rickets. On the 



DENTITION. 29 

other hand, it is by no means invariable that dentition is late in rachitic 
children. The latest dentition is seen in cases of cretinism. In such 
children it is not rare for the first teeth to appear as late as the eighteenth 
month. I have seen one child two years old with but two teeth. As a 
rule, dentition and ossification of the bones of the head go on in a cor- 
responding manner; where one is early the other is likely to be rapid, 
and conversely. 

Provided an infant is well nourished and thrives properly for the first 
six or eight months, the erujjtion of the teeth is likely to go on steadily 
after this time, even though the child may later have chronic indigestion 
or surfer from extreme malnutrition from any cause excepting rickets. 
If, however, the symptoms of malnutrition date from birth, dentition is 
almost invariably delayed. It is often a matter of very great surprise to 
see children who are markedly emaciated as a result of chronic indiges- 
tion or ileo-colitis and yet go on cutting their teeth regularly. I have 
under observation at the present time a delicate infant of sixteen months, 
whose body length is twenty-eight inches and whose weight is less than 
nineteen pounds — almost exactly what they were eight months ago — and 
yet he has now thirteen good teeth. 

Eruption of the Permanent Teeth. — The first to appear are the first 
molars, which usually come in the sixth year, and hence the name six- 
year-old molars, which is applied to them. These appear posterior to the 
second molars of the first set. The following table from Forchheimer 
gives the average time of the appearance of the second teeth : 

First molars 6 years. 

Incisors 7 to 8 

Bicuspids • 9 " 10 

Canines 12 " 14 

Second molars 12 " 15 

Third molars 17 " 25 

The order of appearance, therefore, leaving out the first molars, is 
essentially the same as that of the first set. The permanent teeth, with 
the exception of the molars, take the place of the corresponding deciduous 
teeth. As they grow and push upward they cause atrophy of the roots of 
the first teeth, and gradually cut off their blood supply, so that they 
loosen and fall out. 

The place of dentition as an etiological factor in the diseases of in- 
fancy will be considered in the chapter on Difficult Dentition. 



CHAPTER III. 
PECULIARITIES OF DISEASE IN CHILDREN. 

In many particulars disease in children differs from that of later life. 
These differences relate to etiology, pathology, symptomatology, diagno- 
sis, and prognosis. The greatest contrast to adult life is presented by in-' 
fancy and early childhood. After seyen years, children in their diseases 
resemble adults more than they do infants. 

ETIOLOGY. 

, 1. Inheritance is an important factor. The disease most frequently 
transmitted directly is syphilis. Occasionally tuberculosis and other in- 
fectious diseases have been conveyed directly from the mother to the 
child. In cases where no distinct disease is transmitted, children may 
inherit from parents constitutional tendencies, or a diathesis which may 
manifest itself in infancy, or in some cases not until later childhood. 
Under this head we may place the influence of rheumatism, gout, the 
various neuroses, and possibly alcoholism and insanity. In consequence 
of these conditions in parents, the child may inherit no definite disease, 
but simply a vitiated constitution. 

2. Malformations must be considered, particularly in the first two 
years of life. The most important of these, from a medical standpoint, 
are those of the heart, brain, and kidney. The various malformations of 
the mouth, nose, bladder, rectum, and genital organs belong more particu- 
larly to the domain of surgery. 

3. The Diseases or Accidents Connected with Birth. — Some of these are 
distinctly traumatic, like the meningeal haemorrhages. A very large class 
are the infectious processes in the newly born. Infection usually takes 
place through the umbilical wound, more rarely through the skin or 
mucous membranes. This class includes pyaemia, with its varied lesions 
in the brain, lungs, and serous membranes, erysipelas, ophthalmia, and 
tetanus. In the class of infectious diseases may also be included many of 
the varieties of pulmonary and intestinal diseases in the newly born, and 
probably also some of the haemorrhagic affections. 

4. Conditions Interfering with Proper Growth and Development. — 
These are among the largest etiological factors in the diseases of infancy. 
They are improper food or feeding, unhygienic surroundings, and neglect. 

30 



SYMPTOMATOLOGY AND DIAGNOSIS. 31 

These may cause specific diseases, like rickets or scurvy, or may lead to a 
coudition of general malnutrition or marasmus. In this way they become 
most important predisposing factors, in infancy, to the acute diseases of 
the gastro-enteric tract, and later in childhood, to functional nervous dis- 
eases. 

5. Infection. — This has already been mentioned as an important factor 
in diseases of the newly born. The number of diseases in later life di- 
rectly traceable to this is very large, and is constantly increasing. Under 
this head should be included not only the well-known class of infectious 
or contagious diseases, but also a very large number of varieties of infec- 
tion which as yet have not been differentiated, and the nature of which 
is but imperfectly understood. 

SYMPTOMATOLOGY AND DIAGNOSIS. 

In older children the symptoms of disease are very much the same as 
in adults, and similar methods of examination may be employed. What 
is really peculiar to children belongs especially to the first three years of 
life, before speech has developed. During this period the chief and al- 
most the sole reliance of the physician must be upon the objective signs 
of the disease. It is not so much that diseases in early life are peculiar, 
as that the patients themselves are peculiar. 

Two fundamental facts are always to be kept in mind : First, that the 
common pathological processes are comparatively few, being chiefly of 
the gastro-enteric tract, the lungs, and the brain, but that the variations 
in clinical types are almost endless; the second is, that in infants, on 
account of the susceptibility of the nervous system, functional derange- 
ments are often accompanied by very grave symptoms, and may even 
prove fatal in twelve or twenty-four hours, or there may be speedy and 
complete recovery after very alarming symptoms. In many of these 
cases the symptoms are so indefinite that an exact diagnosis is impossible 
during life, and even the autopsy may throw but little light upon them. 

At the bedside, it is of great assistance to the physician if he can keep 
in mind the most frequent forms of acute disease that are likely to be 
met with. In the first group, including those which are very common, 
may be placed acute indigestion and ileo-colitis, bronchitis, pneumonia, 
pharyngitis, and tonsilitis ; in the second group, including those which 
are not quite so common, may be placed otitis and the acute infectious 
diseases — measles, scarlet fever, diphtheria, influenza, and malaria ; in the 
third group, including the rarer forms of acute disease — meningitis, 
tuberculosis, rheumatism, and diseases of the kidneys. Under all circum- 
stances, the season, and the nature of the prevailing epidemic, if one 
exists, are to be considered. 

In the examination of a sick infant quite a different method is to be 
followed from that pursued in adults. Much information is to be gained 



32 PECULIARITIES OF DISEASE IN CHILDREN. 

from a history carefully taken from an intelligent mother or nurse, and 
much more from a close observation of the child, whether asleep or 
awake, quiet or screaming. 

The History. — The points to be most carefully investigated will vary 
somewhat with the nature of the illness. If the disturbance is one of 
nutrition, the minutest details relating to the character and preparation 
of the food from birth up to the present illness must be considered ; also- 
the progress of dentition, and whether this has been easy or difficult. All 
facts relating to the child's growth and development are significant — the 
period when it was able to sit alone, stand and walk, and its weight. 
Every previous illness should be investigated as to its nature, duration,, 
and severity, especially the eruptive fevers, the diseases of the lungs 
and the digestive tract. All the facts relating to the present illness 
should then be brought out — the exact time and mode of onset, the 
presence or absence of fever, the amount of food taken, the existence of 
cough or hoarseness, the evidences of pain, such as restlessness or scream- 
ing, the character of the sleep, the condition of the bowels, the amount 
of urine passed, and the frequency of micturition. In every case the phy- 
sician should inspect for himself the child's napkins, and never trust to 
the statements of the mother or nurse with regard to the character of the 
faecal discharges or the urine. The question of exposure to any conta- 
gious disease should also be considered. 

In chronic diseases it is of special importance to investigate the sub- 
ject of heredity, from manifestations of disease both in the parents and in 
other children of the family. This is most important with reference to 
syphilis and tuberculosis. The character of the labour should be in- 
quired into, whether it was difficult, prolonged, or instrumental. 

Inspection. — What is learned by the inspection of a sick child will 
depend almost entirely upon the powers of observation of the physician. 
One accustomed to bring out the patient's symptoms by questions is de- 
decidly at a loss to know how to proceed in the case of a sick infant. 
With time, patience and method very much that is important and exact 
can be determined. In fact, the diagnosis of disease in infancy, instead 
of being, as is often supposed, a matter of extreme difficulty or impossi- 
bility, becomes with experience quite as easy as among adults. 

In acute disease when the child is asleep or quiet the following 
points should be noted : 

1. Posture — whether the child lies upon the back, the side, or the 
face ; whether there is opisthotonos, or a general flexion of all the limbs. 

2. Character of the sleep — whether it is quiet and peaceful or dis- 
turbed ; whether there is constant tossing about, grinding of the teeth, 
etc. 

3.. Respiration — whether it is regular, or irregular. This may be deter- 
mined only by careful observation for some minutes. It should be noted 



INSPECTION. 33 

whether it is rapid, or slow, easy, natural, and quiet, or whether there is 
nasal obstruction with snoring and mouth-breathing due to tonsilitis, 
diphtheria, scarlet fever, or adenoid vegetations of the pharynx. The 
best evidence of dyspnoea is the recession of the supraclavicular and 
suprasternal regions, the sinking in of the intercostal spaces, sometimes 
with lateral recession of the chest walls. There is usually present active 
dilatation of the nostrils. 

4. Pulse — whether it is rapid or slow, full and strong or soft and com- 
pressible. The frequency of the pulse in infancy is of much less impor- 
tance than the force and rhythm. A slow, irregular pulse is always sig- 
nificant, and should suggest meningitis ; an irregular pulse, when rapid, 
has no special significance. 

5. Shin — whether it is dry and hot, or covered with perspiration. The 
existence of pallor, general cyanosis, or blueness of the lips and finger 
nails should be noted ; also the circulation in the extremities, whether 
they are warm, or cold and clammy. 

6. Facial expression — whether this is calm and peaceful, drawn and 
anxious, intelligent or stupid, and whether the -features are contracted 
from time to time as if in pain. 

7. Cough — whether this is frequent, difficult, or severe. 

8. Cry : Since this is the chief means by which the infant expresses 
discomfort or displeasure, it becomes exceedingly important but not always 
easy to determine whether an infant cries from pain, discomfort, hunger, 
temper, or from habit. In very many instances the cry under these con- 
ditions is so characteristic that one who is familiar with the child's 
language readily divines what is wrong. It is something which should 
never be disregarded, even though it may be the only obvious symptom. 
Tears are not seen until the second month, so that their absence before 
that time is not to be taken as an evidence that the cry is not from pain. 

The cry of hunger is apt to be interrupted by vigorous sucking of the 
fingers. It is not usually sharp and piercing, like the cry of pain, but it 
is a worrying, fretful cry. It ceases immediately when the hunger has 
be,en satisfied. 

The cry of indigestion is often mistaken for that of hunger, but in 
such cases, although crying may cease for a few minutes after taking food, 
from the temporary relief which this gives, it is likely soon to return with 
unabated vigour. Under such circumstances a frequent repetition of 
feeding or nursing should never be allowed, although very often this is 
just what is done. 

The character of the cry of pain will depend somewhat upon the se- 
verity of the pain. When it is acute like that of colic or earache, it may 
be sharp and piercing, and accompanied by contraction of the features, 
drawing up of the legs, and other evident signs of distress. The child 
falls asleep only when exhausted, and soon wakes, often with a scream. In 



34 PECULIARITIES OF DISEASE IN CHILDREN. 

pain of less severity there is usually moaning, but rarely a sharp cry. In- 
fants cry not only from pain but from every sort of discomfort — wet 
diapers, cold feet, a cramped position, uncomfortable clothing, also if they 
are tired or sleepy, and from a great many other minor causes. The more 
delicate a child the more readily it cries from any cause. 

The cry of weakness and exhaustion is quite characteristic. It may be 
noticed in a great variety of conditions. It is usually a low, feeble whine 
or moan, often nearly constant, except when the child is asleep. 

The cry of temper is not generally heard before the fifth month. It 
is usually accompanied by stiffening of the body, throwing back of the 
head, and sometimes by vigorous kicking. It is loud, violent, and often 
prolonged. 

The cry of habit is one of the most difficult to recognise. These habits 
are formed by indulging infants in various ways. Some children cry to 
be held, some to be carried, some to be rocked, some for a light in the' 
nursery, some for a rubber nipple or some other thing to suck. The 
extent to which this kind of crying may be indulged in, even by very 
young infants, is surprising, and it explains much of the crying of early 
childhood.* The fact that the cry ceases immediately when the child 
gets what it wants is diagnostic of the cry from habit. The only success- 
ful treatment of such cases is to allow the child to " cry it out " once or 
twice, and then the habit is broken. Of course, before such a procedure 
is allowed to go on, one must be well assured that the cry is from this 
cause and no other. 

There are some diseases in which the cry is sufficiently characteristic 
to be of diagnostic importance. Thus we hear the short, catchy, sup- 
pressed cry of pneumonia, the sharp nocturnal cry of tubercular menin- 
gitis and of chronic bone disease, the moan of chronic indigestion and 
acute intestinal diseases, the hoarse nasal cry of hereditary syphilis, and 
the feeble whine of marasmus and of atelectasis. 

9. The mental condition may be one of undue excitement, and it may 
be difficult to tell whether this is from fright at the approach of a stranger 

* On admission to the Babies' Hospital very young infants almost invariably cry a 
great deal for the first two days. It being against the rules to take such children from 
their cribs and hold them to quiet their crying, they soon cease the habit, and give no 
further trouble, crying subsequently only from the usual causes. 

Dr. J. S. Thacher relates an experience which illustrates to what extent this habit 
may be formed in infants of only a few weeks. In a hospital ward under his care, 
containing fifteen or twenty mothers and newly born infants, one of the women was 
seriously ill, and was so annoyed by the crying of the infants that they were allowed to 
be taken from their cribs and held or carried as soon as crying from any cause began. 
After several days the patient was removed from the ward, and for the next two or 
three days the crying in the ward was enough to drive one distracted ; but the mothers 
were forbidden to quiet the infants by taking them up, and after two or three days' 
discipline the crying ceased and peace and order were again restored. 



THE PHYSICAL EXAMINATION. 35 

or from disease. More significant is a condition of apathy and dulness 
and general relaxation in which no resistance whatever is made to the ex- 
amination. Such symptoms always indicate either extreme prostration 
or brain disease. A child may cry from pain or from fright. General 
hyperesthesia is common in meningitis. Soreness of the legs only, sug- 
gests scurvy, rheumatism, or joint disease. 

10. The condition of the pupils should be observed, whether con- 
tracted or dilated, and the nature of the response to light ; also the pres- 
ence of corneal ulcers and the interstitial keratitis so frequent in heredi- 
tary syphilis. The thin mucous film seen over the cornea always indicates 
grave prostration, and often approaching death. 

11. The lymph glands of the neck should be noted : as when swollen 
they may indicate scarlet fever, diphtheria, or simple acute inflammation. 

12. The presence or absence of nasal discharge should be determined, 
and also, if possible, its character. In acute disease this suggests diph- 
theria, scarlet fever, or influenza; if it is chronic, adenoid growths of 
the pharynx, or syphilis. 

13. The appearance of the mucous membrane of the mouth, teeth, and 
gums may often be ascertained by watching the child while it is crying. 
It should be noted whether the tongue is dry or moist, also whether thrush 
is present, or any other form of stomatitis. The condition of the gums 
may be observed, whether congested or swollen or haemorrhagic as in 
scurvy, and also the number, position, and character of the teeth. The 
general colour of the mucous membrane may be significant, as in cases of 
cyanosis. 

Very much can be learned in acute illness by simply watching atten- 
tively a sick child for a few minutes, studying the foregoing points in 
order. By such observation and a carefully obtained history of the ill- 
ness an experienced physician can often make a very probable diag- 
nosis without further examination ; the latter, however, should never be 
omitted. 

The Physical Examination. — Temperature. The first step should gen- 
erally be to ascertain whether or not there is fever. For this one should 
never fall into the habit of trusting to his sense of touch, for it is often 
very misleading. Only the rectal temperature in infants is to be de- 
pended upon, since axillary temperatures are untrustworthy, and those in 
the mouth difficult to obtain. 

Immediately after birth the temperature of the child is about the same 
as that of the mother, or a little above. It falls from 1° to 3° F. in the 
course of the first few hours, under the influence of the bath and radiation 
from the skin during dressing. Very soon it again rises to 98'5° or 99° F., 
near which point, under normal conditions, it remains during the first 
months of life, and in fact throughout childhood. 

From a large number of personal observations upon healthy infants I 



36 PECULIARITIES OP DISEASE IN CHILDREN. 

have found the rectal temperature to vary, under normal conditions, 
between 98° and 99*5° F. Within these limits the temperature may be 
considered normal. The heat-regulating center in the brain acts only 
imperfectly in the young infant, and very slight causes are enough to dis- 
turb the temperature. When the heat equilibrium has once been dis- 
turbed, slight fluctuations may continue for some time after the cause has 
been removed. 

The temperature in infants is always higher than from corresponding 
causes in adults. Moreover, very high temperatures may be met with in 
cases not at all serious, and not infrequently when no explanation can be 
found even after the most thorough examination. In such cases the tem- 
perature very often does not remain at a high point for more than a few 
hours. It is a continuous high temperature rather than a single rise 
which is significant of disease in infancy. Nothing is more perplexing to 
the young practitioner than the frequency with which a high tempera- 
ture is seen in infants in cases of comparatively mild illness. While a 
valuable guide in diagnosis, the temperature alone must not be depended 
upon in early life, nor should its significance be measured by the adult 
standards. 

It is very common in chronic wasting diseases, in delicate infants and 
in those prematurely born, to find the temperature one or two degrees 
below the normal; 95° aud 96° F. are of almost daily occurrence in hos- 
pitals. In one premature infant the temperature on admission was 93° 
F. The feeble heat-producing power of these infants, and the rapid ra- 
diation from their bodies because of the absence of subcutaneous fat, make 
the temperature a very important matter in their nutrition. Daily ob- 
servations should be made with the thermometer, just as in cases of high 
temperature. 

Some of the most puzzling elevations of temperature met with in in- 
fancy are the result of the application of artificial heat. Eross has shown 
by very careful experiments that the body temperature can be raised by 
means of hot bottles or water bags from 1° to 5° F. This is accomplished 
much more readily in the case of feeble or delicate infants than in those 
who are stronger. The truth of his observations I have had abundant 
opportunity to verify in my own experience. This cause must be care- 
fully eliminated in cases where unusually high temperatures appear after 
surgical operations or other prostrating conditions. 

For the purpose of making a systematic routine examination of the 
entire body, the child's clothing, with the exception of the napkin, should 
be removed, and the child laid upon the nurse's lap on a blanket. The 
skin may now be inspected for eruptions, and it is important that the 
entire body be examined. Next the general nutrition of the patient 
should be observed — whether emaciated or well nourished. 

The head should be examined to see whether the sutures are ossified 



THE PHYSICAL EXAMINATION. 37 

or unnaturally open ; whether the fontanel has closed, or, if open, whether 
it is depressed or bulging. 

The details regarding physical examination of the lungs are discussed 
in the introductory chapter of the section devoted to pulmonary diseases. 

In the auscultation of the heart, it should be remembered that under 
two years of age loud murmurs are almost invariably of congenital ori- 
gin ; that soft murmurs are frequently functional, and that acquired or- 
ganic heart disease is extremely rare until after the third year. 

In the examination of the abdomen there should be noted the pres- 
ence or absence of tympanites or abdominal tenderness, whether general 
or localized, and the existence of retraction of the abdominal walls as in 
meningitis. The size and position of the liver and spleen are best de- 
termined by palpation. The lower border of the liver is usually slightly 
below the free border of the ribs. If the spleen can be easily felt below 
the ribs, it is as a rule enlarged. If it can not be felt in a satisfactory ex- 
amination, it is not sufficiently enlarged to be of any diagnostic impor- 
tance. It should be remembered that both liver and spleen may be dis- 
placed downward in rickets from contraction of the chest, giving the 
appearance of slight enlargement when they are normal in size. In acute 
disease a large spleen suggests malaria, typhoid, or tuberculosis ; in 
chronic disease, malaria, syphilis, leukaemia, or anaemia. 

Examination of the urine should not be forgotten. The staining of 
the napkin may give information regarding the discharge of crystalline 
uric acid or of concentrated urine. For other purposes the urine must be 
collected. This is often difficult. The most satisfactory method I have 
found is, in male infants, to tie a condom over the penis ; in female in- 
fants, to put a small cup over the vulva inside the napkin. In those who 
are a year old the urine may readily be collected by putting the child 
upon the chamber every few minutes. It is important not to overlook 
phimosis or balanitis in the male or vulvo- vaginitis in the female, since 
these conditions may not only give rise to local but even to general 
symptoms. 

A careful inspection of the throat should never be omitted in any 
acute illness, no matter what the other symptoms are ; but usually this 
had better be deferred until the last. For this are required a good light 
and a quick glance. Upon the hard palate one may look for the first 
signs of the eruption in measles and scarlet fever, and the condition of 
the throat may be the first and one of the most important signs of both 
the diseases. Diphtheria may exist without pseudo-membrane, and 
marked general redness may be due to scarlet fever, influenza, or simple 
pharyngitis. 

In chronic disease a somewhat different method of examination may 
be followed. The most important diseases because most often met with 
in infancy are, in the first place, those which are connected with nutri- 



38 PECULIARITIES OF DISEASE IN CHILDREN. 

tion, chronic disturbances of the gastro-enteric tract, rickets, and scurvy; 
secondly, syphilis, tuberculosis, chronic diseases of the lungs, diseases of 
the blood, the bones, the kidney, and the heart. 

In the examination, the general development of the child should be 
considered. Its height, weight, circumference of head, chest, and ab- 
domen should be taken and these compared with the average for the 
child's age. The condition of the tissues should be noted, whether firm, 
soft, or flabby ; the ligaments, whether relaxed or not ; the presence of 
bony deformities ; also the existence of pallor, cyanosis, and cachexia, and 
the general nutrition. It should then be determined whether the child 
has for its age a sufficient muscular development, as shown by sitting, 
standing or walking. Its speech, hearing, sight, general intelligence and, 
finally, its mental disposition should be investigated. 

In the local examination special attention should be given to the shape 
of the skull, the condition of the sutures, the size and shape of the fon- 
tanel, and the progress of dentition. It should be noted whether there 
are glandular swellings in the neck or in different parts of the body ; also 
hypertrophied tonsils or adenoids. Finally, there should follow a thor- 
ough examination of the heart, lungs, liver, spleen, blood, urine, bones, 
spine, and joints. The same order need not be followed in every case, 
but the examination should always be thorough, and with the body 
stripped. Unless this is done, serious deformities are often entirely over- 
looked, and an erroneous diagnosis made. 

In children who are old enough to answer questions the same method 
may be pursued as in an adult examination. An important thing in 
dealing with children is a gradual approach, first winning the confidence 
of the child and diverting its attention from the real purpose in view ; 
secondly, the avoidance of every rough examination which might by any 
chance produce pain; and, finally, deferring until the end of the ex- 
amination the inspection of the throat, which must frequently be done 
forcibly, and is sure to interrupt any further chance of intimacy. With 
time and patience almost everything mentioned in the above category 
can be satisfactorily investigated. 

PATHOLOGY. 

The pathological processes which result from intrauterine disease and 
those which are connected with delivery are peculiar to early life. They 
have already been referred to in the section on etiology. Of the processes 
of early life which begin after birth, the first in frequency are those of 
the mucous membranes resulting from the various forms of infection. 
In summer, it is the stomach and intestines which suffer chiefly; in 
winter, the respiratory tract. 

The serous membranes are rarely the seat of primary inflammation. 
The pleura is seldom the seat of primary disease, but very often in- 



^nrm 



PATHOLOGY. 39 

volved secondarily to disease of the lung itself. Affections of the peri- 
cardium and peritonaeum are quite rare. Meningitis is fairly common 
both in the simple and the tubercular form. 

Diseases of the lymph nodes (lymphatic glands) play an important 
part in connection with the acute diseases of the mucous membranes, with 
many affections of the skin and even of the viscera. Acute infection tends 
to excite suppurative inflammation, particularly in infants ; a less active 
process leads to chronic hyperplasia in the mesenteric, mediastinal, and 
cervical glands, in the tonsils, adenoid tissue of the pharynx, etc. The 
lymph nodes in the neck and thorax are frequently the earliest seat of 
tubercular deposits, and in very many cases they are the foci from which 
secondary infection of the lungs, brain, or joints may occur. 

Of the visceral inflammations* those of the lungs are the most com- 

* The following table gives in a general way a very good idea of the relative fre- 
quency of diseases of the different organs in infancy. It is based upon seven hundred 
and twenty-six consecutive autopsies in the New York Infant Asylum, extending over 
a period of eight years during my connection with that institution. More than one half 
of the autopsies I made personally. Of these children seventy-two per cent were 
under one year, twenty-five per cent between one and two years, and only three per 
cent were over two years. The institution does not receive infants under one month, 
hence the absence of lesions peculiar to the newly-born : 

Table showing principal lesions in seven hundred and twenty-six 
consecutive autopsies in the New York Infant Asylum. 
Lungs : 

Pneumonia — Primary 139 

Complicating other acute infectious diseases 112 

Complicating other conditions 71 

Noted to be present in 322 

Pleurisy — No case uncomplicated with disease of lungs. 

Empyema 5 

Serous pleurisy 1 

Dry pleurisy in nearly all the severe cases of pneu- 
monia. 

Atelectasis (congenital) 6 

Pulmonary abscess (always with pneumonia) 7 

Pulmonary gangrene (always with pneumonia) 2 

Pulmonary tuberculosis 56 

Mouth : 

Noma 1 

Peritoneum : 

Acute peritonitis (localized 2, with acute pneumonia and pleurisy 2). . 4 
Kidneys : 

Acute nephritis (complicating scarlet fever 4, diphtheria 1, pneumonia 
4, measles 1, pertussis 1, ileo-colitis 2, pyonephrosis 1, apparently 

primary 5) 10 

Malformations of the kidney 7 



40 PECULIARITIES OF DISEASE IN CHILDREN. 

mon, it being rare to find the lungs normal at autopsy after any acute 
infectious disease which has lasted a week. Up to the third or fourth 
year of life the heart usually escapes. In older children it may be 
involved, as in adults, in the rheumatic diseases. The liver and spleen 
are not often the seat of organic disease in early life, nor is serious disease 
of the kidney likely to be met with excepting in connection with scarlet 
fever. Organic disease of the brain itself is rare, as is also organic dis- 
ease of the spinal cord, with the exception of poliomyelitis. Chronic dis- 
eases of the different viscera are decidedly rare, except when resulting 
from acute processes. Diseases of the bones and joints are common, and 
of extreme importance. They are usually of tubercular, less frequently of 
syphilitic, origin. Diseases of the blood are quite common, but as yet 
but little understood. New growths are rare. The parts most frequently 
the seat are the kidney and the bones. Disorders of nutrition are ex- 
tremely common and of great importance, particularly rickets and scurvy. 

PROGNOSIS AND INFANT MORTALITY. 

The younger the patient the worse the prognosis in all the diseases of 
childhood. This is in consequence of the feeble resistance of the infan- 
tile organism to all diseases, particularly those which are of an acute 
nature. On the other hand, the rapid metabolism of childhood makes 
it possible for many conditions of an organic nature to disappear with 
time, or, as the phrase is, to be " outgrown," provided the patient can 
be so placed that the general nutrition can be carried to the highest 
point. 

The accompanying chart (Plate I) shows the mortality of New York 
city by months during the three years from 1890 to 1892, inclusive, 

Stomach and Intestines : 

Acute ileocolitis, with or without gastritis 116 

Acute gastritis (without intestinal lesions) None 

Acute diarrhceal disease (without gross lesions) 72 

Intussusception 1 

Heart : 

Pericarditis (all with acute pneumonia) 3 

Congenital malformations 3 

Acute or chronic endocarditis None 

Brain : 

Acute, simple, or purulent meningitis (7 with pneumonia, 2 cerebro- 
spinal) 14 

Tubercular meningitis 11 

Acute encephalitis 1 

Chronic pachymeningitis 5 

Chronic simple meningitis 1 

Chronic hydrocephalus 3 

There were twenty-six deaths from marasmus without gross lesions. 



PLATE I. 



1 

1 

1 




Children under 1 year 

1 TO 2 YEARS. 
" 2 TO 5 YEARS 
" 5 TO 15 YEARS. 

Over 15 years. 










1 1 






































































































































Jan. 


Feb. 


Mar. 


APR. 


May 


June 


July 


Aug. 


Sept. 


Oct. 


Nov. 


Dec. 





























































Chart showing by months the mortality of New York city for the different ages 
for three years. (Scale, 1 in. = 2,200 deaths.) 



THE MOST FREQUENT CAUSES OF DEATH. 41 

representing a total mortality of 128,136. This is distributed ai 

different ages as follows : 

Under 1 year 32,916 = 26 per cent. 

1 to 2 years 10,547 = 8 M 

2 to 5 " 9.7U4 = 7 

5 to 15 " 5.470 = .") 

Over 15 " 00.409 = 54 

128,136 

Thus over one fourth of all the deaths occurred during the first 
of life, and over one third in the first two years. The graphic chart 
gives a better idea of this than the figures. It will he noticed that the 
only age in which the mortality is much increased in the summer mouths 
is in the first year. 

According to Eross, who collected statistics from sixteen cities of 
tinental Europe, of 1,439,056 infants born there died in the first four 
weeks of life 130,610, or nearly ten per cent. 

The Most Frequent Causes of Death at the Different Periods of Child- 
hood. — According to Eross, of 94,400 deaths occurring during the first 
four weeks, fifty-six per cent were due to congenital debility. The other 
causes which raise the mortality in this period are asphyxia, infection, 
congenital malformations of the heart, intestine, or geni to-urinary I 
haemorrhages, convulsions, acute attacks of diarrheal diseases, ami pneu- 
monia. Pneumonia is exceedingly common in very young infants, both as 
a primary and secondary lesion. 

Statistics from America and Europe show that in all large cities infant 
mortality has been steadily increasing for the past twenty-fivi 
This is due to many causes — overcrowding, neglect, and unhygienic sur- 
roundings. But more important than all is artificial feeding afl 
ent ignorantly practised. In my experience it lingly ran- t-. find 

a healthy child who has been reared in a tenement house, and who 
been artificially fed from birth. While among the poor the capacity f<-r 
maternal nursing seems to be diminishing year by year, among the better 
classes it has come to be the exception and not tin- rule. In my prii 
practice not one third of the mothers have been able, even though will 
to nurse their infants. But as ignorant and improper feeding an- not 
fined to the poor, we find among rich and poor alike the largest QUI 
of deaths in the first year due to disease of fchi enteric I 

marasmus, either alone or associated. In the Beeond rank con 
diseases of the respiratory trad, especially acute bronchi 
Allother causes of mortality fall far below the.-- two. 
diseases, convulsions and tubercular meningitis are thi 
arecommon. Of the acute infectious diseases pertussis tal 
with measles second, while tuberculosis ranks Him i 
5 



42 PECULIARITIES OF DISEASE IN CHILDREN. 

tions. Although rarely the cause of death, rickets is a very important 
factor in increasing the mortality of other diseases. 

During the second year the deaths from marasmus are few. The dis- 
eases of the gastro-enteric tract are still a large factor in the death rate, 
but by no means to so great a degree as in the first year of life. Nearly 
if not quite as important during this period are the acute diseases of the 
lungs and the acute infectious diseases, especially measles, diphtheria, 
and pertussis. Deaths from scarlet fever are much less numerous. Gen- 
eral tuberculosis and tubercular meningitis are frequent. 

From the second to the fifth year the deaths are mainly from acute 
infectious diseases — chiefly diphtheria and scarlet fever — much less fre- 
quently from measles or pertussis. In the next group come the acute dis- 
eases of the lungs, general tuberculosis, and tubercular meningitis. 

From the fifth to the fifteenth year the mortality in childhood is re- 
markably small, diphtheria and scarlet fever being still in the front rank 
in point of frequency. Next come the acute diseases of the lungs, simple 
as well as tubercular meningitis, diseases of the bones, appendicitis, rheu- 
matism, and cardiac disease. 

Sudden Death. — This is not a very uncommon occurrence in infants 
who are apparently healthy. They are sometimes found dead in bed 
under circumstances in which grave suspicions may unjustly rest upon 
the attendants. The causes are often very puzzling. While sudden death 
sometimes occurs in children who are apparently in perfect health, it is 
very much more frequent in those who are delicate or suffering from mal- 
nutrition. Among this latter class, such as are seen especially in institu- 
tions, sudden death is by no means rare. 

The most frequent causes of sudden death in infants are the fol- 
lowing : 

1. Malformations. — While in most cases, to be sure, malformations of 
a serious nature give rise to symptoms, they may be absent, or may be so 
slight as to be overlooked. Infants may succumb during the first few 
days of life from malformations of the heart, lungs, kidneys, stomach or 
intestines, and sometimes from diaphragmatic hernia. 

2. Internal hemorrhage. — This is chiefly limited to the first two 
weeks of life. In the cases that have come to my notice the cause has 
been rupture of some subperitoneal haemorrhage into the general abdomi- 
nal cavity. The primary haemorrhage is most frequently into the supra- 
renal capsule. It may be beneath the capsule of the liver. Such cases are 
reported in the chapter upon Visceral Haemorrhages in the Newly Born. 
Under these circumstances no symptoms may exist until the occurrence 
of collapse, with death in a few hours. 

3. Asphyxia from overlying. — This is not very common, excepting 
among the lower classes, and is most frequently due to intoxication on the 
part of the mother. Such children after death present the usual -lesions 



SUDDEN DEATH. ao 

of death from asphyxia, but without any evidence of violence. This form 
of asphyxia is most frequently seen in infants a few weeks old. A recent 
writer in the British Medical Journal states that one thousand infants 
die every year from this cause in the city of London alone. 

4. Asphyxia from aspiration of food into the larynx and trachea. 

This may be due to vomiting or to the regurgitation of food during sleep ; 
in a very weak infant it may occur while awake. This is usually seen in 
infants who are less than a year old, and most of the reported cases have 
been under six months. Such children are usually delicate. There seems 
to be vomiting with an attempt at crying, during which the food is drawn 
into the air passages. In some cases, as that reported by Demme, a single 
large clot of milk has been found in the larynx. In others, food is found 
in the larynx, trachea, and large bronchi. Cases have also been reported 
by Partridge and Parrot, and I have myself met with at least three. The 
infants have generally been found dead in bed within a few hours after 
feeding. This accident is more likely to happen when an infant lies 
upon its back. 

5. Asphyxia associated with enlargement of the thymus gland. — I 
have notes of three such cases. Two of them occurred in the New York 
Infant Asylum and one at the Nursery and Child's Hospital. The chil- 
dren were aged respectively three, four, and ten months. The symptoms 
were asphyxia, followed by convulsions and death in a few hours. The 
thymus was in all the cases very greatly enlarged, the weight being over one 
ounce. Only one of these children was markedly rachitic. I have found 
in literature records of fifteen other cases of a similar nature in children 
varying from three to sixteen months. The symptoms in all have been 
similar to those in my own cases. The asphyxia is apparently due to 
pressure upon the pneumogastric. Rickets was present in about 
half of the recorded cases. 

6. Atelectasis.— In very young infants there may be no sympton 
cepting malnutrition until sudden death occurs, sometimes with convul- 
sions and sometimes without any such symptoms. 1 have in several 
instances known death to follow compression upon the lungs bj the 
distended stomach, the symptoms coming on very soon after feedii 
associated with an attack of indigestion. (See Atelectafi 

7. Marasmus.— In this class of cases sudden death is of very con 
occurrence. These children are often as well (wo or three hours t> 
death as for several weeks. Death frequently occurs at night, the 
dren being found dead in bed iti the morning. In Borne of the 
exciting cause seems to be the lowering of the temperature, wrhile in n 
no exciting cause can be found; the vital spark simplj : 
burning for some time with a feeble intensity. In some of thi 
autopsy reveals atelectasis, but in many cases nothing abnormal is I 
death apparently resulting from heart failure. 



44 PECULIARITIES OF DISEASE IN CHILDREN. 

8. Convulsions hi children previously showing no signs of disease. — 
Most of these cases are seen in children who were previously rachitic. 
In them the autopsy shows no lesion except those commonly associated 
with death from convulsions. It is extremely rare for a cerebral lesion 
such as haemorrhage to produce death in this way. In some of these 
rachitic cases death is due to spasm of the glottis. 

9. Asphyxia in older infants and young children. — This may result 
from the pressure of a retropharyngeal abscess upon the larynx or trachea, 
or from the rupture of such an abscess during sleep and the entrance of 
pus into the air passages. While in most such cases other symptoms 
have been present, they may be latent. A rare cause of sudden asphyxia 
in children from eighteen months to five years is pressure upon the 
pneumogastric by tubercular bronchial glands, or by abscesses in the 
posterior mediastinum connected with caries of the spine. I have 
seen examples of both the latter. Gibney has reported a case of sud- 
den death from dislocation of the upper cervical vertebras consequent upon 
caries. 

Sudden asphyxia may follow the ulceration of tubercular lymph nodes 
and the escape of cheesy masses into the trachea or primary bronchi. 
This usually occurs in children from two to five years old, and many cases 
have been reported. 

10. Death after a few hours' 1 illness, in which the chief symptom is 
high temperature. — This is quite a common occurrence. Children who 
are apparently well may be taken with great prostration and a high tem- 
perature, which may rise rapidly to 106° or even 107° F., with death in from 
six to twelve hours, sometimes preceded by convulsions. In my hospital 
experience I have met with many such cases. In infants, the most fre- 
quent explanation of these symptoms, as shown by autopsy, is acute con- 
gestive pneumonia ; in older children it may be due to malignant scarlet 
fever or epidemic meningitis, although I have never seen an instance of 
either of these diseases in which death occurred in the first twenty-four 
hours. 

It does not fall within the scope of this chapter to consider cases of 
sudden death from heart failure after diphtheria, with pleurisy, with effu- 
sion, or with myocarditis. These will be discussed elsewhere. 

PROPHYLAXIS. 

There is no more promising field in medicine than the prevention of 
disease in childhood. The majority of the ailments from which children 
die, it is within the power of man in great measure to prevent. Prophy- 
laxis should aim at the solution of two distinct problems : (1) The re- 
moval of the causes which interfere with the proper growth and develop- 
ment of children ; (2) the prevention of infection. The former can 
come only through the education first of the profession and then the 



THERAPEUTICS. 4:> 

general public, upon the fundamental principles of infant feeding and 
hygiene. This is a department which has received altogether too small a 
place in medical education. The latter must come through the profession, 
and through legislation, the purpose of which shall be more rigid quaran- 
tine, more thorough disinfection, and improved sanitation in alf its depart- 
ments. 

THERAPEUTICS. 

Treatment in the diseases of children, and particularly those of infants, 
is a difficult subject. Therapeutics in infancy consists in something more 
than a graduated dosage of drugs. Many therapeutic means which 
valuable in adults are useless in children, and many others which are of 
little value in adults are extremely useful in children. There is no doubt 
of the truth of the statement that children in the past have suffered much 
from overzealous treatment, particularly from drug-giving. It should be 
a fundamental principle never to give a dose of medicine without a clear 
and definite indication. If this rule is followed, it is surprising to find 
how often medication can be dispensed with, and also, in many cases, how 
much better children do without drugs than with them. A second rule 
is equally important : never to give a nauseous dose when one that is 
palatable will answer the purpose equally well. This is no small matter, 
and one that is well worth the physician's careful attention, if he would 
succeed in the management of sick children. The simpler prescriptions 
are made, the better. As a rule, infants revolt against most of the highly 
seasoned sirups and elixirs which are used to disguise the taste of unpleas- 
ant doses. Bitter medicines, when mixed with water, are frequently ad- 
ministered without the slightest difficulty. 

It is a common mistake to underestimate the importance <»f the hy- 
gienic surroundings of the patient, the value of good nursing, careful 
feeding, and judicious stimulation, just as it is to overestimate the 
ficial effects of drugs. In the great majority of acute ailments no1 Berious 
in character for which a physician is called, the patient recovers qui 
promptly without drugs as with them. This does not mean that Buch 
children require no treatment, but that the least important pari of the 
treatment is drug-giving, while the most important part is attentioi 
the hygienic matters just referred to. In cases of Bevere illness, in ii ' 
especially, we must avoid all unnecessary medication, in order that the 
stomach may not be disturbed and vomiting excited. Hence thi 
tance of relying as far as possible upon local measures -f treatment I h 
tendency to recovery from all acute pr< bile seen in adult 

more striking in children, where, if we can hul remove thai which I 
the bodily functions, Nature will conduct the . 
nation. Thus, after an attack of ordinary bronchitis of I 
it is often seen that the disturbance of the stomach and 



46 PECULIARITIES OF DISEASE IN CHILDREN. 

can be directly traced to the drugs employed, continues long after the 
original disease has subsided, and is very much more difficult to relieve. 
In diseases of the stomach and intestines especially there is a great amount 
of overmedication, very much to the detriment of the patient. In all 
chronic disturbances of nutrition — chronic indigestion, malnutrition, and 
anasmia — nothing is of so much value as change of air and surroundings. 
This is most striking in the case of city children. With them it is a fre- 
quent experience that tonics of every description are of little or no avail, 
and yet immediate and most marked improvement begins when the chil- 
dren are sent to the country. 

The tablet triturates have furnished us with a convenient method of 
administering many drugs to children. Those which are especially useful 
are calomel from one tenth to one half grain ; gray powder in the same 
doses ; antimony and ipecac, one one-hundredth of a grain each ; phena- 
cetine, one to two grains ; arsenious acid, one one-hundredth of a grain ; 
paregoric, lUv ; Dover's powder, one tenth of a grain ; atropine, one four- 
hundredth to one two-hundredth of a grain. This list might be very 
greatly extended. 

As to the method of administration, it is to be remembered that 
several small doses are more easily given and less likely to disturb the 
stomach than a few larger ones. This method of administering very 
many drugs to children will be found extremely satisfactory — e. g., 
sodium bromide, one half grain every fifteen minutes, is often better 
than five grains every two hours ; phenacetine, one half grain every half 
hour, is better than two grains every two hours ; calomel, one tenth of a 
grain every hour, is better for constipation than a single dose of two 
grains. 

Antipyretics. — The indications for the employment of antipyretics in 
children are somewhat different from those in adults. It is to be borne 
in mind that, where the cause is similar, all temperatures in children are 
higher than in adults. Thus a simple pharyngitis, which in an adult 
causes a rise of temperature only to 100° or 101° F., is in a child not in- 
frequently accompanied by a temperature of 104°, or even 105° F. The 
height of the temperature, as measured by the thermometer, is not to be 
taken as the only guide for the employment of antipyretics. In many 
cases the temperature is 104°, or even 105° F., and yet the child exhibits 
no signs of unusual discomfort. Such a temperature manifestly does not 
call for interference. Again, a temperature of 103° F. may be accom- 
panied by very marked restlessness and other signs of distress which 
may be relieved by employing some antipyretic measure. The number 
of cases seen in practice, of high temperature apparently from trivial 
causes, is very great. One must not be unduly alarmed even by a very 
high temperature if it is of short duration. It is the continuously high 
temperature which indicates serious illness. Whenever the temperature 



ANTIPYRETICS. ah 

is found to be much, above the normal it should be carefully watched, 
but not interfered with until a diagnosis has been made, unless the 
symptoms urgently demand it ; otherwise the physician may lose one of 
the most valuable aids to diagnosis, since it is not the height of the 
temperature but its course which is significant. The routine practice of 
ordering full doses of antipyretic drugs whenever on the first visit au 
elevation of three or four degrees is discovered can not be too Btrongly 
deprecated. In many cases it is very important to know whether the tem- 
perature uninfluenced by drugs is remittent, intermittent, or steadily 
high, and hence the advantage of waiting until a diagnosis has been made 
before disturbing the temperature curve, always provided, of course, that 
the child is in no danger from the high temperature— a condition which is 
certainly not common. Since the cause of a great many obscure tempera- 
tures is found in the stomach and intestines, it very often happens that a 
purgative, stomach-washing, or intestinal irrigation may be the most effi- 
cient antipyretic. In cases of moderate elevation of temperature we need 
go no further than cold sponging. 

The most reliable antipyretic measure for infants is the use of cold. 
This may be employed — 

(1) As an ice cap to the head. — In many cases of quite high tempera- 
ture and restlessness in infants this alone will reduce the temperature 

or two degrees and allay the nervous symptoms. It may be \\>ck\ continu- 
ously or intermittently, according to circumstances. 

(2) Cold sponging. — For this purpose water about 80° to s "' P., equal 
parts of alcohol and water, or equal parts of vinegar and water may be 
employed. In the case of infants, all the clothing except the diaper 
should be removed and the child laid upon a blanket. The body should 
be sponged for from ten to twenty minutes, preferably under the blanket 
which is thrown over the body. Cold sponging must be very frequently 
employed in order to be efficient in reducing high temperature, Its great 
value in allaying nervous symptoms, even when the temperature is not 
very high, is not sufficiently appreciated. Its effeel is often more satis- 
factory than an anodyne. 

(3) Cold pack.— This is one of the simplest and most efficient means 
of reducing temperature which can be employed. The child should be 
stripped and laid upon a blanket. The entire trunk Bhould then be 
enveloped in a small sheet wrung from water at a temperature of LOO I 
Upon the outside of this, ice may now be rubbed over the entire trunk, 
first in front and then behind. By this method there is no shook and 
no fright, and any ordinary temperature can usually be readily redu 
The rubbing with ice should he repeated in from five to thirty mi in 
according to circumstances, after which the child may be rolled i 
blanket upon which he is lying without the removal of th 

The head should be sponged with cold water while thi 



48 PECULIARITIES OF DISEASE IN CHILDREN. 

on, and artificial heat, if necessary, should be applied to the feet. The 
pack is continued from one to twenty-four hours, according to cir- 
cumstances. 

(4) The cold lath. — This is more easily employed in the case of infants 
than larger children. The child is put into a bath at a temperature of 
100° F., the bath being gradually lowered by the addition of ice to 85° or 
80° F. The body should be well rubbed while the child is in the bath and 
water should also be applied to the head. On removal from the bath, the 
body should be quickly dried and rolled in a warm blanket. The bath is 
usually continued from five to twenty minutes. 

(5) Irrigation of the colon is an efficient means of lowering the tem- 
perature. The water should be from 40° to 50° F. ; it should be injected 
through a catheter, and not more than a pint should be introduced at one 
time. It is not to be advised except in cases of colitis, where the double 
purpose of lowering the temperature and cleansing the intestine may be 
accomplished at the same time. 

Antipyretic Drugs. — Except in cases of malaria, quinine should not be 
employed for the reduction of temperature in children. The dose required 
is so large, the difficulty of administration is so great, and the tendency to 
upset the stomach is so uniform, that its use should be discouraged alto- 
gether ; besides, its effect is extremely uncertain. 

Of the three antipyretics more recently introduced — phenacetine, anti- 
pyrine, and antifebrine — their value in children is in the order named. 
Phenacetine, has the advantage of being tasteless, but the slight disadvan- 
tage of being insoluble. Antipyrine is so bitter as to make its administra- 
tion often difficult. The prostration attending the use of antifebrine is 
rather greater than that of either of the others. None of these drugs is, 
however, to be employed in large doses with the sole purpose of reducing 
the temperature. Their great value in paediatrics consists rather in allay- 
ing the nervous symptoms which accompany fever, and this purpose can 
be accomplished by the use of comparatively small doses. To an infant 
of one year, phenacetine or antipyrine can be given in one-grain doses 
every hour or two hours until the desired effect is produced. For a child 
of five years a dose of two grains may be given in the same manner. When 
used as indicated, these drugs are of very great value in making the patient 
more comfortable, in promoting sleep, and in allaying headache and gen- 
eral pains. In cases of hyperpyrexia they are, however, much less certain 
and less safe than the use of cold. In many cases of mild pyrexia the symp- 
toms are relieved by the administration, either separately or in combination, 
of citrate of potassium, spiritus setheris nitrosi, and liquor ammonii acetatis, 
in small frequent doses. 

Stimulants. — In spite of the many statements to the contrary, alco- 
holic stimulants are well tolerated even by very young infants. Propor- 
tionately larger doses of alcohol than of most drugs may be administered 



STIMULANTS. 

to infants ; still, stimulants, and alcohol in particular, are no doubt \ 
greatly abused in the hands of many practitioners. 

The indications for the employment of stimulants are much the same 
in young children as in adults. They are to be used whenever the pulse 
is weak, soft, and compressible, and whenever the general powers of the 
patient are very greatly depressed. In most of the acute fevers thej 
not to be given early in the disease, and in many cases they are Dot re- 
quired at all ; but whenever the patient's general strength is great lv 
reduced, and what is known as the typhoid condition develops, they are 
to be used freely, whatever the disease may be. They must often be 
very sparingly while the temperature is high, but given freely as soon as it 
falls. In many acute febrile diseases stimulants are not called for at any 
period. This is especially true of most cases of lobar pneumonia. The 
time, however, when they are most likely to be needed is at or just after 
the crisis of the disease, when for twenty-four hours they should be very 
freely given. In broncho-pneumonia they are more uniformly required, 
and their use should be begun earlier. This is particularly true of the 
broncho-pneumonia which develops secondarily to the infectious (lis- 
In all toxic diseases, such as diphtheria, alcohol should be begun as Boon 
as depressing symptoms show themselves, and continued in doses regu- 
lated by the degree of prostration. In the acute gastro-enterie (li- 
the depletion is often so great and there is so little absorption of food that 
the patients must in certain cases be sustained by alcohol for several 
days. 

Alcoholic stimulants are contraindicated in all acute febrile pro 
where there is high temperature, dry skin, flushed face, and a lull, Btrong 
pulse. In such conditions they are often injurious. 

The method of administering stimulants is of no little importance. 
Brandy and whiskey are in most cases to be preferred to the wines, hut 
not always. Champagne may be substituted when spirits are QOi well 
borne by the stomach. For infants under one year old, brandy should 
be diluted with at least eight parts of water. It ifi commonly given in 
too concentrated a form. Altogether the best method of administra- 
tion is to determine the amount to be given in every twelve hours, 
it diluted sufficiently, and then administer it in -mall do aort 

intervals. In this way vomiting is rarely produced. The addition «-f 
brandy to the water required by the thirst makes il less likely to dial 
the stomach. 

The quantity of alcohol will depend very much upon ciroumst 
An infant one year old, for whom alcoholic Btimulants are needed al all, 
should be given, to begin with, half an ounce of whiskej or brandy durin 
twenty-four hours, the quantity being increased for a Bhorl 
ounce and a half, or in bad cases even to two ounces : b 
if ever, advisable to go beyond this limit. 



50 PECULIARITIES OF DISEASE IN CHILDREN. 

In children four years old double the amount may be employed in the 
corresponding conditions. Larger quantities than those mentioned are of 
doubtful advantage. Alcohol when used injudiciously is capable of doing 
much harm. 

Tonics. — Cod-liver oil stands at the head of the list of tonics for young 
children. It is particularly in the convalescence after acute diseases of 
the respiratory tract that we see its most striking benefit. It is also of 
very great use in anaemia, and in a large number of children who are 
extremely delicate. In these patients it may be advantageously adminis- 
tered throughout the greater part of nearly every winter season. In con- 
valescence after attacks of gastro-enteric disease it is not nearly so useful, 
and often must be withheld for a long time. It is a mistake to give cod- 
liver oil at any time when the tongue is coated, the digestion poor, and the 
stomach easily disturbed. In the case of infants, as a rule, the pure oil 
is to be preferred to the emulsions, but this is not always the case. The 
administration of small doses — i. e., ten or twenty drops of the oil three 
times a day continued for a long period — is much better than the use of 
larger doses for a shorter time. 

A perfect preparation of iron for use in infancy has not yet been dis- 
covered. During the first few years all astringent preparations should be 
avoided. For use at this age the best forms are probably the bitter wine, 
Robin's peptonate, Gude's peptomanganate, Drees's albuminate, and the 
malate of iron. The peptonate and peptomanganate have the advantage 
of mixing easily with milk. For older children nothing is more satisfac- 
tory than Blaud's pills. 

Arsenic is second only to iron in the treatment of the anaemia of chil- 
dren, and in very many cases it is to be preferred to iron. The tablet 
triturates of arsenious acid, one one-hundredth of a grain, may be given 
immediately after meals three times a day, or one or two drops of Fowler's 
solution largely diluted with water. 

Alcohol is of very great value as a tonic in combination with some of 
the bitters, either small doses of quinine, nux vomica, or the bitter wine 
of iron. Usually wines, especially sherry, are to be preferred to spirits, 
although some children take spirits better. When combined with a bitter 
there is little danger of the formation of the alcoholic habit, even though 
its use may be long continued. 

Of the bitter tonics, quinine and nux vomica are easily superior to all 
others. 

Opiates. — Strong objections have been urged by many against the 
employment of opium in the diseases of infancy. While opiates have 
no doubt been abused, the fact remains that opium is almost as valu- 
able a remedy in the treatment of disease during the first five years 
as at any other period of life. Infants are, however, peculiarly suscep- 
tible to the drug, and relatively much smaller doses are required than 



OPIATES— ANODYNES. 



51 



of most medicines. If the physician will accustom himself to the use 
of very small doses, he will be surprised to see how satisfactory are the 
effects produced. 

The most useful preparations for young children are paregoric. 1 > 
powder, the deodorized tincture, morphine, and codeine. The folio 
table gives what may be considered a safe initial dose at the different 
ages : 



Paregoric 

Deodorized tincture 
Dover's powder 

Morphine 

Codeine 



1 month. 



mi 

Gr. -gV 
Gr. toW 
G-r. ^o 



3 months. 



m ii 

Gr.^ 
Gr.^ 
Gr. iroTT 



1 


year. 


m 


V to X 


m 


itoi 


Gr. 




Gr. 


Ybn 


Gr. 


& 






TT1 XX' 

tti ii t«. iii 
Gr. ii to iii 

Gr. A to) 



Ordinarily doses like the above should not be repeated oftener than 
every two hours. In exceptional circumstances, as when very great pain 
is present, the dose may be given more frequently. In the hypodermic 
use of morphine it should be remembered that its effects are always more 
uniform and striking than when the drug is administered by the mouth. 
and the dose should therefore be smaller. In every instance where a full 
dose of opium has been given the physician should wait until tl. 
have subsided before the dose is repeated. 

Anodynes.— Chloral is usually well borne even by quite young infants. 
In them it should never be administered by the mouth, but, on account 
of its irritant properties, always by the rectum. After rectal adminisl 
tion its effects are usually manifest in half an hour, and sometimes Booner. 
The dose for an infant of one month is one grain ; three months, two 
grains; one year, three to five grains. It may be repeated every tw< 
four hours, according to indications. Other drugs may replace this in 
most diseases, but in the case of infantile convulsions nothing ifl bo reliable 
as chloral. 

Belladonna is well borne by children, and in larger doses than most 
drugs. A tolerance is quite readily established. The eruption ifl more 
readily produced than the other physiological effects.and even quite mi. ail 
doses may be sufficient to bring out a very abundant blush. Tin- pare 
should be advised of this fact, lest undue alarm be felt 

The drugs classed as antipyretics— phenacetine, antipyrine, 
febrine— are exceedingly valuable in the treatment of man) d 
infancy where irritative nervous symptoma an- prominent 
they mav advantageouslv take the place of opium, 
the principal symptom, as in otitis or pleurisy. In all 
spasm is a prominent symptom, whether of the larynx or 
or general convulsions, antipyrine Is especially valuable. 



52 PECULIARITIES OP DISEASE IN CHILDREN. 

Drugs well borne by Children. — In this list might be mentioned 
belladonna, the bromides, the iodides, chloral, quinine, calomel — in fact, 
all mercurials — and alcohol. 

The drugs not well borne include particularly cocaine and all prepa- 
rations of opium. In the case of many others, while the constitutional 
effects are well tolerated, they must' be given carefully to young infants, 
since they are irritants to the stomach. In this class may be mentioned 
the salicylates, salol, the astringent preparations of iron, and the acids. 

Counter-irritants. — These are of great value in a large variety of dis- 
eases. Blisters should never be employed in the case of infants, and very 
rarely, and never needlessly, in the case of older children. In the latter 
they may be required in inflammations of the ear, of the joints, or of the 
spine ; they should never be applied to the chest. 

The mustard paste is probably the most satisfactory means of pro- 
ducing quick counter-irritation over a large surface. To make a mustard 
paste : Take one part powdered mustard and six parts of wheat flour, mix 
with lukewarm water, and spread between two layers of muslin. This 
should be removed as soon as a thorough redness of the skin has been 
produced — in most cases from five to eight minutes, according to the 
strength of the mustard employed. This may be repeated as often as 
every three hours, and continued for a week if necessary, without pro- 
ducing excoriations of the skin. For older children the paste may 
be made one part mustard to four parts flour. In pulmonary diseases 
it should be large enough to surround the chest. When it is used 
to produce general reaction in heart failure it should cover the entire 
trunk. 

The mustard pack. — The child is stripped and laid upon a blanket, 
and the trunk is surrounded by a large towel or sheet saturated with 
mustard water. This is made as follows : One tablespoonf ul of mustard 
to one quart of tepid water. In this a towel is dipped, and while drip- 
ping wound around the entire body. The patient should then be rolled 
in the blanket. This pack may be continued for ten or fifteen minutes, 
at the end of which time there will usually be a very decided redness of 
the whole body. It may be repeated according to indications. Where it 
is desired to produce a general counter-irritation, the mustard pack is not 
quite as efficient as the mustard bath, but it has the advantage in causing 
much less disturbance to the patient. The mustard pack is useful in the 
condition of collapse or of great prostration from any cause whatever, in 
convulsions, and in cerebral or pulmonary congestion. 

The turpentine stupe is made by wringing a piece of flannel out of 
water as hot as can be borne by the hand. Upon this is sprinkled ten or 
fifteen drops of the spirits of turpentine. The stupe is then applied to 
the body and covered with oiled silk- or dry flannel. It is useful chiefly 
in abdominal pains or inflammations, but in infancy must be carefully 



POULTICES. 



53 



watched or vesication will be produced. For continuous use it is not bo 
valuable as the mustard paste. 

Stimulating liniments containing turpentine and other irritants are 
useful in inflammation of the chest, although less reliable than the mus- 
tard paste. One of the mildest and most useful preparations is camphor- 
ated oil. Another is olive oil four parts and turpentine one part. 'I 
may either be rubbed upon the surface, or a piece of flannel may be satu- 
rated with them and then applied to the skin. The old-fashioned spice 
bag is useful in many cases where a very mild counter-irritant is desired 
over the abdomen. 

Dry cups may be used even in young infants, to relieve acute pul- 
monary congestion. They are sometimes of very great value, and may 
succeed in cases in which there is no reaction from the mustard. Prom 
four to six cups may be applied, and the effect may be continued by the 
application of the mustard paste. Wet cups should never be used in 
young children. 

Poultices are useful in local inflammations about the glands of the 
neck, the joints, and in cellulitis in various parts of the body. The pro- 
longed use of poultices can not be too strongly condemned in ca& 
otitis. In diseases of the chest poultices may do harm because their 
weight embarrasses respiration, and sometimes because of the exposure 
when they are changed. They are most useful in pulmonary diseases in 
which there is great pain, as in pleurisy or in pleuro-pneumonia. In 
bronchitis and in broncho-pneumonia they are objectionable, certainly for 
prolonged use, on account of their weight. Better effects can generally be 
produced by hot fomentations and counter-irritation. Ground flaxseed is 
the best material for poultices. This should be mixed with boiling w\ 
until the proper consistency is reached, when the poultice should be put 
into a bag of muslin. The poultice should be covered with oiled Bilk or 
cotton batting, so that it will retain its heat as long as possible. To be of 
value, poultices must be applied hot and changed frequently. 

Hot fomentations are more cleanly than poultices and much 
easily changed. One of the best means of applying them is by a pieoe of 
spongio-piline wrung from water as hot as the hand can bear. Where 
this can not be obtained, a large piece of flannel may be u>v>\ in the - 
way, covered with cotton batting, and then with oiled silk. Thia method 
of using hot fomentations is exceedingly satisfactory forappli the 

extremities. 

Cold.— Cold is useful in all forms of inflammation of 
brain. In inflammation of the cervical lymph glands and of 
is of undoubted value, but its advantage over heat is questionabl< 
efficiency of both cold and heat in thee : . v "!" ,: 

method of application. Sometime, in pleurisy mm 
tained from the use of an ice bag to the chesl than from bol 



54 PECULIARITIES OF DISEASE IN CHILDREN. 

but this is not the general experience. The treatment of pneumonia by 
the application of the ice bag to the chest has some excellent advocates, 
although my own experience has not led me to look upon it with much 
favor. It is admissible only in lobar pneumonia. The use of cold in in- 
flammations of the larynx, trachea, or bronchi is, in my opinion, positively 
contraindicated, certainly so in infants and young children. 

Cold is best applied to the head by an ice cap made like a helmet ; an 
ordinary rubber or flannel bag filled with ice may answer the purpose. 
The rubber coil filled with ice water is also an excellent method. For 
inflamed glands or joints the ice bag should be used ; for the eyes cold 
compresses changed every minute. 

The Hot Pack. — All clothing is to be removed and the child's body 
covered with towels wrung from water at a temperature of from 100° to 
110° F., after which the body should be rolled in a thick blanket. These 
hot applications may be changed every twenty or thirty minutes until free 
perspiration is produced, which may be continued as long as necessary. 
This is mainly useful in uraemia. 

The Hot Bath, like the mustard pack or the mustard bath, may be 
used to promote reaction in cases of shock or collapse. The patient should 
be put into the bath at a temperature of 100° F., the water being gradu- 
ally raised to 110°, or even to 115°, but rarely above this point. The body 
should be well rubbed while the patient is in the bath. A thermometer 
should be kept in the water to see that the temperature does not go too 
high. During the bath, in most cases, cold should be applied to the head. 

The Hot-Air or Vapour Bath. — All the clothing should be removed 
and the patient laid upon the bed with the bedclothing raised above the 
body ten or twelve inches, and sustained by means of a wicker support. 
The bedclothing should be pinned tightly about the neck, so that only 
the head is outside. Beneath the bed clothing hot vapour is introduced 
from a croup kettle or a vapourizer. This will usually induce free per- 
spiration in fifteen or twenty minutes. It may be continued from twenty 
to thirty minutes at a time. Instead of vapour, hot air may be intro- 
duced in the same way. The air space about the body is indispensable. 
The vapour bath is applicable chiefly to cases of uraemia. 

The Mustard Bath. — Four or five tablespoonfuls of powdered mustard 
should be mixed for a few minutes with one gallon of tepid water. To 
this should be added four or five gallons of plain water at a temperature 
of 100° F. The temperature of the bath may be raised by the addition of 
hot water to 105° or 110° F. if desired. Nothing is more efficient than 
the hot mustard bath for a general derivative effect in bringing the blood 
to the surface in cases of shock, collapse, heart failure from any cause, or 
in sudden congestion of the lungs or brain. The bath should not usually 
be continued for more than ten minutes. If necessary, it may be repeated 
in an hour. 



NASAL SPRAY. 55 

The Bran Bath. — Put one quart of ordinary wheat bran in a bag made 
of coarse muslin or cheese cloth and place this in four or five gallons of 
water. The bran bag should be frequently squeezed and moved about 
until the bath water resembles a thin porridge. It may be of any tem- 
perature desired, but usually about 90° to 95° F. is best. A bran bath is 
of great value in cases of eczema, excoriations about the buttocks, or in 
other cases where the skin is very delicate, and plain water seems to irri- 
tate it. 

The Tepid Bath may be given at a temperature of 95° to 100° F. It is 
very useful in many conditions of excitement or extreme nervous irrita- 
bility. To induce sleep it is often more efficient than drugs. 

The Cold Sponge or Shower Bath should be given in the morning 
before breakfast, and in a warm room. The child should stand in a 
foot tub containing warm water enough to cover the feet, then a I; 
sponge holding about a pint of water at a temperature of from 40° to G0° 
F. should be squeezed three or four times over the chest, shoulders, and 
spine of the child, the skin being rubbed meanwhile. The bath should 
not last more than half a minute. It should be followed by a brisk rub- 
bing until a thorough reaction is established. This is very useful at all 
ages, but a particularly valuable tonic in delicate children. It may be 
used in those only eighteen months old. Not the least of the beneficial 
results is the full expansion of the lungs from the strong cry which the 
bath usually excites. In younger infants a cold plunge may be sub- 
stituted. This should be merely a single dip of the entire body in 
water at a temperature of 50° to 60° F. In order that beneficial effects 
shall follow the cold plunge or cold sponging, a good reaction must be 
established. If children lack suffi- 
cient vitality to secure this, and if 
they remain pale, pinched, and blue 
for some time after the bath, it 
must be discontinued altogether, 
or water of a higher temperature 
used. 

Nasal Spray. — This may be either 
of an aqueous or oily solution. For 
the oil spray an atomizer similar to 
that shown in the accompanying 
cut should be employed. It is valu- 
able in cases of dry catarrh, where then- is a formation of orusj 
nose. A variety of oils mav be used in the spray, albolei 
haps as satisfactory as any. Fig. 8 shows an efficii 
albolene. 

There are a good many forms of hand atomi e found 1 

market for the production of an aqueous spray. I 




56 PECULIARITIES OF DISEASE IN CHILDREN. 

spray, Dobell's* solution, Seller's f solution, Listerine ten-per-cent solu- 
tion, or a two-per-cent solution of boric acid may be used. 

Nasal Syringing. — In cases of considerable nasal obstruction and in 
the more serious affections of the rhino-pharynx only the syringe can be 
considered an efficient means of cleansing the cavity. The nasal syringe 
should be small enough to be easily worked with one hand. It should 
have a soft-rubber tip to prevent injuring the nose, and the tip should be 
large enough to fill the nostril. The best syringe for nasal use is shown 
in Fig. 9. This is made either of glass or hard rubber and fulfils all the 




Nasal syringe. 



conditions mentioned. J It is easy of action, can be readily cleansed, and 
holds about half an. ounce. The same syringe should not be used for more 
than one patient, unless it has been very thoroughly disinfected. In hos- 
pitals, and even in private practice, nasal syringes are frequent carriers of 
infection. Two positions may be used in nasal syringing. In diphtheria, 
scarlet fever, or any constitutional disease attended by great depression, the 
child should not be removed from the bed. The syringing may be done 
by a single nurse who stands at the head of the bed, alternately syringing 
the right and left nostril, turning the head from side to side (Fig. 10). 
The other method is to hold the child erect on the lap with the head in- 

* Dobell's solution : 

Sodium biborate 3 j 

Sodium bicarbonate 3 j 

Glycerin of carbolic acid 3 ij 

Water to make half a pint. 

f Seller's solution : 

Sodium bicarbonate 3 j 

Sodium biborate. § j 

Sodium benzoate gr. xx 

Sodium salicylate gr. xx 

Eucalyptol gr. x 

Thymol gr. x 

Menthol gr. v 

Oil gaultheria gtt. vj 

Glycerine § viij ss. 

Alcohol § i j 

Water to make sixteen pints. 

This is also sold in tablets, one of which is dissolved in four ounces of water to 
make the solution of the above strength. 
$? X This is made by the Goodyear Company. 



NASAL SYRINGING. 



57 



clined a little forward, the syringing being done by a person who stands 
behind. In syringing, the water should come out of the opposite nostril 
or out of the mouth, to make it certain that the rhino-pharynx has been 




IL L .— - - -p A 
I* I \ 



Fig. 10. — Method of syringing the nose. 

reached. When properly done, no prostration and very little irritation 
are caused. 

Syringing the mouth and pharynx is useful in many pathological con- 
ditions of these parts, particularly in children too young to gargle. 
Either an ordinary hard-rubber piston syringe or a bulb (Davison) svi- 
inge may be used. If the pharynx is to be reached, the nozzle is used as a 
tongue depressor. This should be placed at the angle of the mouth be- 
tween the back teeth* The child should be held in the Bitting postnre, 
with the head inclined forward. Only mild solutions should be employed. 
6 



58 



PECULIARITIES OP DISEASE IN CHILDREN. 



Inhalations. — These are of very great utility in all affections of the 
respiratory tract. To be efficient, the patient should be put under a tent. 
A satisfactory tent may be made by erecting a T-shaped piece of wood at 
the head and foot of the crib and throwing over this a large sheet folded 
and pinned at the corners. Another method is, to stretch a cord around 
the top of each of the four posts of the crib, or simply from the centre of 
the head piece to the centre of the foot piece ; the sheet should be used as 
in the first instance. A very good tent may be improvised by throwing a 
large sheet over an open umbrella. Instead of an ordinary cotton sheet 
one of rubber cloth may be used. For hospital use I have found it con- 
venient to have a rubber cover made to fit closely over the top of the crib 
to be used for inhalations. The better the tent the more satisfactory are 
the results from inhalations. 

Inhalations may be in the form of vapour or spray. The apparatus 
employed may be the croup kettle, the vapourizer, or the steam atomizer. 
As all of these are used with alcohol lamps, innumerable accidents from 
fire have occurred with them. Patients and nurses should always be cau- 
tioned regarding this. The ordinary croup kettle is a clumsy affair and 
especially likely to be the cause of accidents. In Fig. 11 is shown one 
of an improved pattern,* which possesses the advantages both of the ordi- 
nary croup kettle and of the 
vapourizer. The base has been 
weighted, to prevent the appa- 
ratus being easily upset. The 
pail is low, which fact also contributes 
to its stability. It is provided with a 
safety alcohol lamp, the flame of which 
can be regulated by a screw. The 
lamp holds enough alcohol to burn 
from five to six hours. This kettle 
may be used to produce simple vapour, 
or vapour from lime water, or a medi- 
cated vapour may be employed. If the 
latter is desired, the substance to be va- 
pourized is placed on a sponge held in 
the expansion of the spout. The kettle 
should be filled with hot water before 
using. It should be placed upon the 
floor or a low box beside the crib, so that the end of the spout is just in- 
side the tent at a level with the surface of the bed. 

The vapourizer f (Fig. 12) is one of the most satisfactory means of 




-Croup kettle 



* Made by Lewis & Conger, New York. 

f Made by Whitall & Tatum, Philadelphia. 



OILED-SILK JACKET. 



59 



obtaining medicated inhalations. The boiler is half filled with water, and 
the substance to be vapourized is placed upon a sponge which lies on a per- 





apourizer. 



Fig. 13. — Steam atomizer. 



forated diaphragm placed at the top of the boiler, so that all the steam 
generated in the boiler passes through it. 

The steam atomizer is shown in Fig. 13. For this no tent is required. 
It should be placed about one and a half or two feet from the patient's 
face, and the clothing protected by a rubber sheet. This is very efficient 
where steam or vapour of lime water are used, but is not to be advised for 
carbolic acid, creosote, etc. 

Oiled-silk Jacket. — In all forms of acute pulmonary inflammation this 
form of local application has largely supplanted the time-honoured poul- 
tice, both in hospital and in private practice. It keeps the skin at a uni- 
form temperature, maintains a moderate degree of counter-irritation, and 
gives the patient a great deal of comfort. The jacket consists of three 
layers — an outer one of oiled 
silk, an inner one of cheese 
cloth or gauze, and a middle 
one of cotton batting or wool. 
The middle layer should be 
half an inch in thickness. 
The purpose of the lining is 
to keep the cotton in posi- 
tion. Fig. 14 shows the pat- 
tern of the jacket. It is gen- 
erally made in two pieces, 
each of which should be about 

twelve inches wide and twelve inches long for a child of one year. These 
are sewed together along one border and lapped at the other, where it- 
is secured by safety pins A properly made jacket will last two weeka 




Patters for oiled-silk jacket 



60 



PECULIARITIES OP DISEASE IN CHILDREN. 





Stomach-Washing consists in the introduction of water into the stom- 
ach through a flexible catheter or stomach tube and then siphoning it 
out. It was introduced into general practice among infants by Epstein, 
of Prague. To Seibert (New York) is due the credit of bringing the 

subject prominently before the minds of 
the medical profession in America. It is 
one of the most valuable therapeutic 
measures we possess. Stomach-washing 
has been employed almost daily for the 
past seven years in the hospitals with 
which I am connected, during which 
period the stomach has been washed 
many thousand times. No accident 
whatever has occurred, and the operation 
may be considered entirely free from 
danger; in fact, it is difficult to pass 
the tube anywhere else than into the 
oesophagus. The amount of prostration 
may be compared to that of an ordinary 
attack of vomiting. 

The apparatus for stomach-washing 
is very simple (Fig. 15). There is re- 
quired a soft-rubber catheter, size 16, 
American scale (24 French) — one with a 
large eye is preferred ; a glass funnel, 
holding four to six ounces ; two feet of 
rubber tubing, and a few inches of glass tubing to join this to the cathe- 
ter. The child should be held in a sitting posture (Fig. 16), the body 
well protected by a rubber sheet, with a large basin conveniently near. 
The catheter should be moistened. While the tongue is depressed with 
the forefinger of the left hand, the catheter is passed rapidly back into the 
pharynx and down the oesophagus. It is important that the first part 
of the introduction should be as rapid as possible, for if the child begins 
to gag from the pharyngeal irritation the introduction of the tube may 
be quite difficult. No resistance is ordinarily encountered after the tube 
reaches the oesophagus. About ten inches of the catheter should be passed 
beyond the lips. When it has reached the stomach the funnel should be 
raised as high as possible, to allow the escape of gases almost invariably 
present. It should then be lowered, in order to siphon out the fluid con- 
tents. If nothing escapes, the funnel is then to be raised and from two 
to four ounces of water poured into it from a pitcher ; the funnel is then 
lowered and the water siphoned out. This procedure is repeated from 
four to ten times, or until the fluid comes back perfectly clear. About a 
pint of water is ordinarily used. Various solutions have been advised 



Fig. 15. — Apparatus for stomach- 
washing-. 



STOMACH- WASHING. 



61 



for stomach-washing, but nothing is better than boiled water, used at the 
temperature of from 100° to 110° F. — the higher temperature being em- 
ployed when the gastric irritation is very great. Through the tube are 
easily discharged mucus and small curds ; larger ones are gradually broken 
down by repeated washing. Vomiting may be induced by overdistending 
the stomach with water. If there is great thirst there is often an advan- 
tage in leaving one or two ounces of water in the stomach. To this water 
it is at times beneficial to add lime water. 

Stomach-washing in its application is practically limited to children 
under two and a half years. It is easiest in those under eighteen months. 




Via. 1(3. — Position for stomach- washing. 

Children of three years and over are usually so much alarmed and struggle 
so violently as to make it difficult and undesirable. 

The indications for stomach-washing are : 1. In acute indigestion, 
either with or without persistent vomiting. Here the purpose is simply 



64: PECULIARITIES OF DISEASE IN CHILDREN. 

the upper part of the colon has been reached. The water is passed from 
time to time alongside the catheter, often with considerable force. At 
least a gallon of water should be used for a single irrigation. The wash- 
ing should be continued until the water returns quite clean. Gentle 
kneading of the abdomen should be continued during the irrigation, par- 
ticularly the early part of it, to facilitate the passage of the water into the 



,* ( " 






V 




■ ■■v^r : ~>w ? . ]& . 



Fig. 17. — Colon of a child six months old, in position. (From a photograph.) 

upper part of the colon. At the end of the irrigation the rubber tube is de- 
tached and the water allowed to escape through the catheter, which remains 
in situ. Sometimes as much as a pint of water remains in the intestine. 
This is usually passed within half an hour. As the irrigation of the colon 
almost invariably excites active peristalsis of the lower ileum, this part of 
the intestine is emptied as well. It is to be remembered that the colon 
of an infant six months old will hold one pint without distention, and at 
the age of two years from two to three pints. 

Irrigation of the colon is useful to clear this part of the intestine of 
mucus, faecal matter, undigested food, and the products of decomposition. 



ENEMATA. 65 

It may also be employed as a means of local medication in ileo-colitis. 
Where the object is simply to cleanse the intestine, a saline solution — a 
teaspoonful of common salt to a pint of water — is preferred. In cases of 
inflammation of the colon various astringent injections may be used ; but 
the employment of antiseptic injections is of doubtful advantage. 

The temperature of the water used for irrigation may be varied accord- 
ing to the special indications. For ordinary purposes, where cleansing 
only is aimed at, the temperature of from 75° to 85° F. seems to be best. 
When the body temperature is high, or when there is much pain, tenes- 
mus and straining, ice water has important advantages. The patient's 
temperature may often be reduced as effectively by an ice-water injection 
as by a bath. In cases of collapse or great prostration hot injections may 
be employed; these should not be higher than 110° F., but at this tem- 
perature they may be used with safety. 

Irrigation under most circumstances is required only once in twenty- 
four hours. When it is employed it is important to use a large quantity 
of water. In cases of ileo-colitis with severe symptoms two irrigations a 
day may be advantageous. This means of treatment certainly forms a 
most valuable addition to our therapeutics in the management of intesti- 
nal diseases. With ordinary care irrigations are free from danger. They 
must be done thoroughly to be of value, and either by the physician him- 
self or an experienced nurse. The chief points of importance are, that 
the catheter should be introduced high into the bowel, and that a large 
quantity of fluid should be employed. 

Enemata. — Simple enemata are useful in infants and older children, 
to empty the bowels in cases of constipation. Where an immediate effect 
is desired the most efficient is one containing glycerine — e. g., for an 
infant, one teaspoonful to one ounce of water. Oil enemata are useful 
where the faecal mass is hard and dry and expelled with difficulty. For 
this purpose from two drachms to half an ounce of sweet oil may be given. 
Enemata should always be given with care, and preferably a rubber tube 
should be attached to the nozzle of the syringe, since injury may be done 
by a hard-rubber or metal tip. 

Nutrient enemata are of very little value in infancy. In older chil- 
dren they may be used as in adults. For this purpose either completely 
peptonized milk or some of the forms of beef peptones, like Mosquera's 
beef jelly, may be employed. In giving stimulants in enemata care should 
always be taken that they be well diluted — one part of brandy to at least 
eight parts of water. 

The administration of drugs per rectum is useful in certain cases 
where, on account of the unpleasant taste or vomiting, the administration 
by mouth is difficult. In this connection we may mention particularly 
quinine and chloral. As a diluent milk is preferable to water. If quinine 
is used, the bisulphate is the best preparation, but this must be well diluted. 
7 



QQ PECULIARITIES OF DISEASE IN CHILDREN. 

The use of stronger solutions than four grains to the ounce often results 
in the production of rectal catarrh. The temperature of all enemata which 
are to be retained should be about 100° F. It is necessary in infancy to 
press the buttocks together for at least an hour afterwards to prevent the 
expulsion of the injection. 

Hypodermic Medication. — This is not often used in childhood, but it 
must not be forgotten that it is at times of the greatest service even in 
infancy. The use of morphine hypodermically in convulsions, of mor- 
phine and atropine in cholera infantum, of atropine in opium poisoning, 
of strychnine in heart failure, as in pneumonia and syncope, may be cited 
as examples. These are all conditions in which the hypodermic needle 
may save life. 

Massage. — In older children massage is useful for the same conditions 
as those for which it is employed in adults ; the most important are 
anaemia and general malnutrition — in conjunction with the " rest treat- 
ment " — in chorea, and in chronic constipation. For the last mentioned 
only abdominal massage is employed. The special method of doing this 
will be referred to in the chapter on Constipation. In children, even more 
than in adults, it is necessary that in the beginning only the mildest move- 
ments of massage should be employed, and these but for a short time. 

In infancy massage has a limited application, and it is doubtful 
whether it really does more than can be accomplished by the general 
friction of the body. This rubbing, either with the bare hand, or with 
cocoa butter, or some other fat, is very useful in all forms of malnutrition, 
in rickets, and in wasting diseases where the circulation is feeble and the 
muscular tone low. Any form of fat may be employed for inunction. 
Cocoa butter is cleanly and has a pleasant odor, and is, I think, quite as 
valuable as the more commonly employed cod-liver oil, which is exceed- 
ingly disagreeable. The inunctions should be given daily after the morn- 
ing bath, the child lying upon the nurse's lap before an open fire, covered 
only by a blanket. The rubbing should be continued for fifteen to twenty 
minutes each time. 



PART II 



SECTION I. 
DISEASES OF THE NEWLY BORN. 

CHAPTER I. 
ASPHYXIA. 

The lungs in the full-term foetus are of a uniform dark red colour, and 
show very distinctly upon their surface the lobular divisions. They are 
firm and solid and readily sink in water. The connective tissue is very 
abundant, and forms distinct fibrous septa, which stretch through the 
lungs in every direction. 

Inflation of the lungs begins with the first cry uttered by the infant 
as it is born into the world. The parts first expanded are the anterior 
borders of the lungs, then the upper lobes, and finally the lower lobes 
posteriorly. The superficial lobules are nearly always expanded before 
those in the interior of the lung. The inflation is sometimes irregular, 
because of the accumulation of mucus in some of the bronchial tubes. 
The right lung is frequently stated to be expanded earlier than the left. 
Although this is often the case, there is no uniformity in this respect. 
The important point to be remembered is, that the parts last inflated are 
the posterior portions of the lower lobes. The expansion of the lungs is a 
gradual process, and in healthy infants it is probably not complete much 
before the end of the second day. In delicate children it may be post- 
poned for several days, or even weeks. The above statements are based 
upon post-mortem observations upon infants dying from various causes 
during the first weeks. It has often been a matter of great surprise to 
find at autopsy on an infant two or three days old, that less than one half 
of the lung tissue was expanded, although the child had breathed well 
and shown no signs of atelectasis. Under normal conditions at full term 
inflation of the lung takes place very readily, but not so readily in pre- 
mature or delicate infants, on account of the feebleness of the respiratory 
muscles. The longer it is postponed after birth the more difficult does it 
become, on account of the changes which occur in the collapsed air vesi- 

67 



68 DISEASES OF THE NEWLY BORN. 

cles. The condition of the child in utero may be described as one of 
foetal apncea, its oxygen being received and its carbon dioxide discharged 
through the placenta, which is essentially the organ of respiration at this 
period. This condition is interrupted by cutting off the supply of oxygen 
and the accumulation of carbon dioxide in the blood. Which of these is 
the important factor in inducing pulmonary respiration has been much 
debated ; but the best experimental evidence seems to show that it is the 
want of oxygen which stimulates the respiratory centres. 

Under the term " asphyxia " may be included all cases in which pri- 
mary respiration is not spontaneously established with sufficient force to 
maintain life. Usually there is no attempt at pulmonary respiration until 
after the birth of the child, but it may occur in utero or at any stage of 
parturition. Asphyxia may be of intra-uterine or extra-uterine origin. 

Etiology. — 1. Intra-uterine asphyxia. The maternal causes include 
any disturbance of the placental circulation during labour — anything 
which prolongs the second stage of labour, convulsions, haemorrhage, the 
use of ergot in the second stage, or, finally, the death of the mother. The 
causes relating to the child are pressure upon the cord, multiple winding 
of the cord about the neck, early separation of the placenta, and pressure 
upon the brain. If the respiratory stimulus comes before the birth of 
the child, the effort at respiration may cause the entrance into the mouth 
and air passages of amniotic fluid, mucus, blood, meconium, etc. 

2. Extra-uterine asphyxia. This condition is a much less common 
one. It arises from causes quite apart from those above mentioned, and 
depends upon malformations or intra-uterine disease of the organs of 
respiration, circulation, or of the brain. It may be secondary to an injury 
of any of these organs received during parturition. It is also seen in pre- 
mature infants, where it depends upon the feeble development of the nerve 
centres and respiratory muscles and upon the soft, yielding chest walls. 

Lesions. — In infants dying of intra-uterine asphyxia there are seen 
the usual changes found in death from suffocation, together with the effects 
of attempts at breathing in utero. There is general congestion of all the 
viscera, particularly of the brain and its meninges, the liver, and the lungs. 
They may show small, punctate haemorrhages, and occasionally large ex- 
travasations. Blood or bloody serum may be found in any of the serous 
cavities. The right heart is overdistended with dark, soft clots, and the 
blood generally is more fluid than normal. The lungs may contain no 
air, but more frequently there are small, scattered areas in which lobular 
inflation has taken place. If the child has lived several hours there are 
larger areas of expanded lung, especially in the upper lobes, and these 
may even be emphysematous, if artificial inflation has been employed. 
In the mouth, nose, larnyx, and even as far as the finest bronchi, there 
may be found aspirated materials — amniotic fluid, blood, mucus, or me- 
conium. In extra-uterine asphyxia there are organic changes in the vis- 



ASPHYXIA. 69 

cera — malformations of the lungs or the heart, intra-uterine pneumonia 
or pleuritic effusion, malformation of the diaphragm and sometimes of 
the brain. 

Symptoms. — Under normal conditions the newly-born infant begins at 
once to scream and to use its limbs, the purplish colour of the skin giving 
place in a few moments to a rosy pink. In the first degree of asphyxia — 
asphyxia livida — the child is deeply cyanosed. Either no attempt what- 
ever is made at respiration, or it is superficial and repeated only at long 
intervals. The pulse is slow, full, and strong. The vessels of the cord 
are distended. Muscular tone is preserved, and also cutaneous irritability, 
so that with the application of almost any kind of external stimulus, respi- 
ration is excited and the symptoms disappear. 

In the second degree— asphyxia pallida — the picture is quite a different 
one. The face is pale and death -like, though the lips may still be blue. 
The heart's action is weak, and by palpation can rarely be felt at all. By 
auscultation the sounds are feeble, irregular, and usually slow. The cord 
is soft, pale, and flaccid, and its vessels nearly empty. The sphincters are 
relaxed, and meconium oozes from the anus. There is entire loss of tone 
in the voluntary muscles, so that the extremities and entire body seem 
perfectly limp. Cutaneous sensibility is abolished. The extremities are 
often cold. There may occur a few short, convulsive contractions of the 
respiratory muscles, but these are without effect and soon cease. Unless 
such cases receive the most prompt and efficient treatment, the heart's 
action becomes more and more feeble until it ceases and death occurs. 
Other cases are partly resuscitated and may survive for a few hours or 
days, when they gradually sink, respiration becoming more and more 
feeble in spite of all efforts to maintain it. Between these two extremes 
all degrees of severity are seen. 

In extra-uterine asphyxia there may be some attempts at voluntary 
respiration continuing for several hours, sometimes for a day or two, but 
this may be inadequate to sustain life. 

Diagnosis. — Almost the only condition with which asphyxia is likely 
to be confounded is cerebral compression from a meningeal haemorrhage. 
The difficulties in the case are much increased by the fact that the two 
conditions are not infrequently associated. It may then be impossible to 
tell that in addition to asphyxia, intracranial haemorrhage is present. If the 
haemorrhage is extensive and the asphyxia only moderate, a diagnosis is 
possible in most of the cases. In haemorrhage there is often a history of 
undue compression during delivery — sometimes the use of forceps. The 
fontanel is bulging ; there is coma, and there may be paralysis. The re- 
spiratory murmur may be quite strong for several hours, but it gradually 
fails as the child becomes completely comatose. Anaemia resulting from 
a large haemorrhage, like that due to rupture of the cord, may simulate the 
severe form of asphyxia. 



70 DISEASES OF THE NEWLY BORN. 

Prognosis. — This depends upon the grade of asphyxia and the treat- 
ment employed. There is but little tendency to spontaneous recovery in 
any form. In the milder cases recovery is almost invariable with any 
intelligent treatment. In the severest cases the outcome is always doubt- 
ful, although by persistent effort many that are apparently hopeless may be 
saved. In a prognosis as to the ultimate result, the frequent complica- 
tion of asphyxia with meningeal haemorrhage should always be kept in 
mind. Apart from this complication it is doubtful whether asphyxia has 
anything to do with the production of idiocy. 

Treatment. — In every case the first step is to clear the mouth and 
pharynx of mucus by means of the finger covered with absorbent cotton. 
In the milder forms respiration is usually excited either by spanking the 
child or the alternate use of hot and cold baths. If the hot bath is em- 
ployed, the water should be from 110° to 120° F., or about as hot as the 
hand will bear. After a few moments the child may be dipped into cold 
water, or the body may be douched with it. In the livid cases relief is 
often afforded by allowing the cord to bleed for a few moments before liga- 
tion. The loss of half an ounce of blood is ordinarily sufficient. Simply 
swinging the child in the air is a powerful stimulus to respiration. The 
above means will suffice in the great majority of cases. In the more severe 
forms, however, these are inadequate. There is no response whatever to 
external stimulation, either by heat or mechanical irritation. In these 
cases two methods of resuscitation may be employed : artificial respiration 
and direct inflation of the lungs. 

One of the most widely employed methods of inducing artificial respi- 
ration is that of Schultze. The infant is grasped by both axillae in such 
a way that the thumbs of the physician rest upon the anterior surface of 
the chest, the index fingers in the axillae, and the remaining fingers extend- 
ing across the back. The child is thus suspended at arm's length between 
the knees of the physician, the feet downward and the face anterior. The 
body is now swung forward and upward, until the physician's arms are 
nearly horizontal. This produces the inspiratory effort. When this point 
is reached an arrest in the swinging, causes flexion of the trunk, the head 
now being directed downward, the lower extremities fall towards the phy- 
sician until the whole weight of the body rests upon the thumbs. In this 
way expiration is produced. Lusk cautions against the employment of 
this method if the heart's action is very feeble, as it may cause it to stop 
altogether. 

A method introduced by Dew has been extensively employed in New 
York. The infant is grasped in such a way that the neck rests between 
the thumb and forefinger of the left hand, the head being allowed to fall 
far backward, the upper portion of the back resting upon the palm of the 
hand ; with the right hand the knees are grasped between the thumb 
and fingers, the thighs resting against the palm of the hand. Inspiration 



ASPHYXIA. 71 

is produced by depressing the pelvis and lower extremities thus causing 
the abdominal organs to drag upon the diaphragm, and at the same time 
gently bending the dorsal region of the spine backward. In expiration 
the movement is reversed, the head being brought forward and flexed 
upon the thorax, while at the same time the thighs are flexed so as to 
bring them against the abdomen. The body is thus alternately folded 
upon itself and unfolded as the movements are carried on. If there is 
much mucus in the mouth, the movement of expiration should first be 
made with the body completely inverted. This method is simple, efficient, 
and much less fatiguing than that of Schultze when it is to be main- 
tained for a long time. It is also of great advantage in that it can be 
carried on while the child is in the hot bath, one of the greatest objec- 
tions to the method of Schultze being the loss of animal heat incident to 
its use. 

In all cases where artificial respiration is used the first movement 
should be that of expiration, to expel, so far as possible, foreign substances 
from the air passages. The movements should be made from eight to 
twelve times a minute, and not too forcibly, the child being kept in the 
hot bath between the movements, and as much as possible during them. 
As long as the heart beats resuscitation is possible, and the case should 
not be abandoned. 

Inflation of the lungs is not usually of so much general value, although 
it is sometimes successful when all other means have failed. It may be 
done by the mouth-to-mouth method, or by the introduction of a catheter 



Fig. 18. — Ribemont's laryngeal tube for inflating the lungs. 

into the larnyx. The former is much easier, but is much less certain, 
since the air is liable to pass into the stomach. If, however, the head be 
carried pretty well backward, compression made over the epigastrium, and 
the nose closed, this is less likely to occur. The introduction of a flexible 
catheter into the larynx is by no means an easy matter even with consid- 
erable practice. The use of a stiff catheter is not so difficult, but it is capa- 
ble of doing harm. A much better instrument is the laryngeal tube of 
Eibemont (Fig. 18). This is inserted like an intubation tube. By means 
of the rubber bag attached, air may be forced into the lung, or mucus 
aspirated from the trachea and bronchi as may be desired. In all these 
methods, but especially when the catheter is used, care is necessary not to 
employ too much force. It should always be remembered tbat the ca- 



Y2 DISEASES OF THE NEWLY BORN. 

pacity of the lungs of the child is much less than that of those of the 
physician. Like artificial respiration, inflation is to be used in connec- 
tion with the external application of heat, preferably the continuous hot 
bath. 

A method lately introduced by Laborde, of making rhythmical traction 
upon the tongue eight to ten times a minute as a means of exciting respira- 
tion, is one of the most efficient within our reach. It may be resorted to 
in conjunction with other methods, or used alternately with them. 

In cases of asphyxia it is not enough to make the child cry. The 
deep respirations must be made to continue, for very often it happens 
that resuscitation is only partial, and that the child after six or eight 
hours lapses into its previous condition. All severe cases require careful 
watching for the first twenty-four or thirty-six hours, as a repetition of 
the treatment is often required. 



CHAPTER II. 

CONGENITAL ATELECTASIS. 

This condition is one in which there is a persistence of the foetal state 
in the whole or in any part of the lung. 

Atelectasis is the pathological condition with which asphyxia of the 
newly-born is usually associated. In most of the cases the condition of 
atelectasis is completely overcome by the means employed in resuscitation ; 
in some, however, these means are only partially successful, so that a por- 
tion of lung of variable extent remains in the foetal condition. These are 
the circumstances in which most of the cases of atelectasis arise. But 
there are others in which there is no history of early asphyxia, where the 
primary respirations, although taking place spontaneously, have not been 
of sufficient force and depth to produce full pulmonary expansion. This 
usually occurs in feeble infants, or in those who are premature. The 
causes of congenital atelectasis are therefore, in the main, those mentioned 
as producing asphyxia. 

Lesions. — In cases where the child dies during the first few days the 
amount of expanded lung is often very small, frequently not more than 
one fourth of the pulmonary area. The expanded portion is usually the 
anterior borders of the upper lobes. This is often the seat of acute em- 
physema, the rest of the lung being still in the foetal state. It is of a 
brownish-red colour, very vascular, does not crepitate, and shows the lobu- 
lar outlines both on the surface and on section. With a little force the 
atelectatic lung may be completely inflated. 

If children have lived several months, nearly the whole of the upper 



CONGENITAL ATELECTASIS. 73 

lobes and the anterior portion of the lower lobes are usually well inflated. 
These portions are either normal or slightly emphysematous. The pos- 
terior portion of the upper lobes and the lower lobes are almost invariably 
the seat of the atelectasis. On the surface even these portions may pre- 
sent quite a large area of expanded vesicles, but the lobe is solid to the 
touch, and crepitates but slightly. On section it is seen that only the 
most superficial part of the lung is inflated, often only to the depth of 
a line, while the interior of the lobe is unexpanded. Small haemorrhages 
are frequently seen beneath the pleura. 

It is usual for both lungs to be affected, and often, but by no means 
uniformly, to about the same degree. It is frequently a great surprise to 
discover that a child has lived two or three months without presenting 
any signs of cyanosis, using not more than one third of its pulmonary area. 
This variety of atelectasis closely resembles the hypostatic pneumonia of 
delicate infants, and very often the two conditions are associated. It may 
require the microscope to decide between them. If congenital atelectasis 
has existed for some months, there are usually found evidences of pneu- 
monia. Inflation is not so easy as in recent cases, but with force the 
greater part of the lung can usually be expanded. The heart commonly 
shows the right auricle and ventricle to be distended with dark clots, and 
there is occasionally found a patent foramen ovale or some other form of 
congenital lesion. The liver and spleen are in most cases congested, and 
the spleen may be considerably enlarged. The mucous membrane of the 
stomach and intestines is sometimes deeply congested. 

Symptoms. — In one group of cases the children are asphyxiated at 
birth, but the attempts at resuscitation have been only partially successful. 
Although the patients may live for a few days, there is cyanosis, which 
gradually deepens, and death takes place from asphyxia, exhaustion, or 
convulsions. 

In a second group of cases the infants have been asphyxiated at birth, 
and resuscitated perhaps with difficulty, but to all appearance completely. 
They do not thrive, however, remaining small and delicate, gaining very 
little or not at all in weight, and showing poor circulation, cold extremi- 
ties, and occasionally subnormal temperature. It is characteristic of these 
cases that the cry is never loud, strong, and lusty. Some of them will not 
cry at all. Such children may live several weeks, or even months. There 
may develop at any time, often quite suddenly and without assignable cause, 
attacks of cyanosis with prostration. Children may have several such at- 
tacks, which do not excite suspicion since they pass away spontaneously. 
In other cases the symptoms are so severe that they may result fatally in a 
few hours, death being frequently preceded by convulsions. If energetically 
treated the symptoms may pass away but, reappearing in a few hours, or 
again after a week or more, they gradually deepen in intensity until death 
occurs. 



74 DISEASES OF THE NEWLY BORN. 

Two cases coming under my observation in the New York Infant 
Asylum in 1890, illustrate this point. The infants were twins, ten weeks 
old and delicate. Suddenly at night one child was taken with convul- 
sions, became deeply cyanosed, and died in two and a half hours. It had 
been suffering from a slight attack of indigestion and diarrhoea for a week 
previous, but apparently was not seriously ill. The other twin had been 
on the previous day as well as for several weeks. Two hours after the 
death of the first child the second was taken. with similar symptoms, dying 
in a few hours. At autopsy I found very extensive atelectasis involving 
the posterior part of the upper and the greater part of both lower lobes. 
The lesions were almost identical in the two cases. In both, the stomach 
was greatly distended with food and gas. I have repeatedly seen the 
effect of overdistention of the stomach in producing cyanosis in young 
children, and in this instance I believe it to have been the exciting cause 
of the final symptoms. It was subsequently learned that during the six 
weeks of observation the nurse had witnessed several slight attacks of cy- 
anosis in one of the infants. 

I have seen a number of such cases, in which there was nothing what- 
ever to attract attention to the lungs until the final attack of cyanosis 
occurred, the children showing only the signs of malnutrition. In not all 
of these cases is there a history of asphyxia at birth. Some are only puny, 
delicate or premature, exhibiting during the early weeks of life all the 
signs of feeble vitality. The subsequent course is the same as in those in 
which there is early asphyxia. The duration of life in these cases depends 
chiefly upon the extent of the atelectasis. 

It is not to be supposed that all cases of congenital atelectasis ter- 
minate fatally. Infants in whom there is every reason to believe that 
atelectasis exists, from the occasional attacks during the first few weeks of 
cyanosis, feeble cry, poor circulation, etc., may under favourable conditions 
recover completely, even though no special treatment is directed to the 
lungs. 

Diagnosis. — For this the physical signs are of much less value than the 
symptoms. It should be remembered that the principal seat of the disease 
is the lower lobes posteriorly. Percussion usually gives resonance over the 
entire chest, although this may be somewhat diminished posteriorly. There 
is not, however, so much change as one would expect to find, for the col- 
lapsed areas are surrounded by others which are overdistended, and there 
are in the midst of the collapsed parts, especially upon the surface, lobules 
which are inflated. If the two sides are involved to about the same degree, 
as is often the case, we can get no difference in the percussion note over 
the two lungs, and the change from the normal may be so slight as not to 
be appreciable. Where only one lung is affected a difference can usually 
be made out. The respiratory murmur is rarely bronchial, but generally 
only feeble in its intensity, and rather ruder in quality than normal. As 



ICTERUS. 75 

in the case of percussion, if only one lung is affected this is of some value 
in diagnosis, but it is not sufficiently marked to be readily recognized 
when both sides are involved. Occasionally rales are present. 

Treatment. — In the newly-born child, whether asphyxiated or not, the 
physician should see to it that the infant not only cries, but does so 
loudly and strongly, and that this cry is repeated every day. If children 
do not cry naturally they must be made to do so by the alternate use of 
the hot and cold bath, as in cases of asphyxia, or by mechanical means, 
like spanking. This should be repeated at least twice a day, and con- 
tinued for from fifteen to thirty minutes. It may seem cruel, but it is 
often the only means of saving life. Expansion of the lungs is much 
more easily induced during the first few days of life, becoming more and 
more difficult the longer it is delayed. Provided the condition is recog- 
nized, treatment is fairly successful. In institutions where delicate infants 
spend most of the time in their cribs, atelectasis is likely to be found. 
An infant needs exercise, and this is often only to be obtained by taking 
the child from its crib several times a day, by general friction, massage, 
the stimulus of fresh air, etc. Nothing is more certain to perpetuate 
atelectasis than to allow the infant a life of feeble vegetative existence. 
Food and feeding must be carefully attended to, but even these are of less 
importance than the maintenance of the animal heat. The temperature 
is often subnormal, and should be closely watched. If there is difficulty 
in keeping the child warm it should be rolled in cotton and surrounded 
by hot bottles, or kept in an incubator during the first few weeks. (See 
page 10.) During attacks of cyanosis the same means are to be employed 
as in cases of asphyxia of the newly-born — cutaneous stimulation and arti- 
ficial respiration — the administration of drugs being of little or no value. 



CHAPTER III. 
ICTERUS. 

Several varieties of icterus are met with in the newly-born. 

1. It is often seen in the various forms of pyogenic infection. In 
such cases the icterus is usually mild. 

2. It may depend upon syphilitic hepatitis — a rare cause. 

3. It may be due to congenital malformations of the bile-ducts. 

4. The most frequent of all varieties is the so-called idiopathic icterus, 
sometimes spoken of as " physiological " icterus. 

In the cases included under the first and second heads icterus is a 
minor symptom. The other varieties are sufficiently important to require 
separate consideration. 



76 DISEASES OF THE NEWLY BORN. 

MALFORMATIONS OF THE BILE-DUCTS. 

The common bile-duct is the most frequently affected. There may be 
atresia at the point where it opens into the intestine, the duct may be 
represented by a fibrous cord, or it may be absent altogether. In many 
cases this is the only lesion ; in others it is associated with an impervious 
hepatic or cystic duct ; in still others the common duct is normal, but 
the cystic or hepatic ducts are impervious. 

At autopsy all the organs are usually found intensely jaundiced, par- 
ticularly the liver. In recent cases this is very much swollen, but pre- 
sents no marked organic changes. In cases which have lasted several 
months there is commonly found chronic interstitial hepatitis, sometimes 
to a very marked degree. This was present in nine of the fifty cases col- 
lected by Thompson.* The gall-bladder is usually small, and often rudi- 
mentary. In cases of atresia of the common duct it may be greatly dis- 
tended. 

The condition of the bile-ducts is ascribed to an error in development 
and subsequent catarrhal inflammation. There does not seem to be suf- 
ficient evidence to prove that hereditary syphilis is an etiological factor 
of much importance. This was present in but five of Thompson's 
cases. 

Symptoms. — The most striking symptom is jaundice, which is usually 
noticed a day or two after birth, and steadily increases until it becomes 
intense. The urine is colored a dark brown or bronze by bile pigment, 
and even the meconium stools may be white, except in cases where mal- 
formation is limited to the cystic duct. The liver as a rule is much en- 
larged. The spleen is often swollen. Haemorrhages beneath the skin or 
from any of the mucous membranes are quite common. Vomiting is 
usually absent. In most cases there is progressive wasting, and death 
within the first few weeks. Of Thompson's fifty cases, nine lived less 
than a month, and only eighteen over four months. Lotze has reported 
a case of a child living eight months with an impervious hepatic duct. 
A frequent cause of death in the rapid cases is convulsions. 

These malformations cannot be influenced by any treatment. 

PHYSIOLOGICAL OR IDIOPATHIC ICTERUS. 

In 900 consecutive births at the Sloane Maternity Hospital icterus, 
was noted in 300 cases. In 88 it was intense, in 212 it was mild. Ac- 
cording to the statistics of various lying-in hospitals of Germany, it was 
found in from 40 to 80 per cent, of all infants. In the 300 cases just 
referred to, icterus was noticed on the first day in 4, on the second day in 
19, on the third day in 72, on the fourth day in 86, on the fifth day in 67, 

* Edinburgh Medical Journal, 1892. 



ICTERUS. 77 

and on or after the sixth day in 44. From the second to the fifth day is 
therefore the nsual period for its appearance. 

It usually increases in severity for one or two days and then slowly 
disappears. The average duration in the mild cases is three or four days ; 
in those of moderate severity about a week ; in the most severe cases it 
may last for two w r eeks. The icterus is first noticed in the skin of the 
face and chest, then in the conjunctivae, then in the extremities. The 
skin varies in colour from a pale to an intense yellow. The urine in most 
cases is normal. It sometimes is of a light brown colour, and only in the 
most severe cases does it contain bile pigment. According to Eunge, both 
urea and uric acid are produced in larger amounts than in children not 
icteric. The stools are unchanged, the normal yellow evacuations occur- 
ring in the icteric as early as in those not affected.' 

According to some observers, in infants who are icteric the initial loss 
in weight is greater and the subsequent gain slower than in other children. 
This is not borne out by the Sloane statistics. Of the 300 icteric children, 
155 made satisfactory progress in every respect and gained rapidly. The 
progress in 106 cases was said to be "fair"— i. e., at the time of dis- 
charge, usually on the tenth day, a slight gain in weight was noted. 
The remaining 39 did badly, not gaining in weight and showing other 
symptoms of malnutrition. The proportion of icteric infants who did 
well, moderately, and badly, was practically the same as of the other 
children in the institution not suffering from icterus. Icterus occurs with 
equal frequency in both sexes. According to Kehrer, it is more frequent 
in first children than in later ones, and considerably more frequent in 
premature children than in those born at term. The presentation, the 
duration of labour and its character — whether natural or artificial — have 
no influence upon the production of icterus. As a rule icteric children 
appear in other respects healthy, but in those below the average size the 
icterus is apt to be more intense. 

Few subjects have given rise to wider speculation than this form of 
icterus. Its exact pathology is at present unknown. Of the many theo- 
ries advanced, that of Silbermann is perhaps the most satisfactory — viz., 
that the icterus is due to resorption, and is hepatogenous in its origin. 
With this view Frerichs and Schultze agree. Silbermann explains the 
resorption by the existence of stasis in the capillary bile-ducts which are 
compressed by the dilated branches of the portal vein and the blood capil- 
laries. The change in the circulation of the liver is one of the results of 
the change in the blood which occurs soon after birth. This results from 
an extensive destruction of the red blood cells — a kind of blood fermenta- 
tion. The more feeble the child the more intense the icterus, because 
the blood changes are more intense. In consequence of this destruction 
of red blood cells abundant material for the formation of bile pigment 
exists and accumulates in the hepatic vessels. 



78 DISEASES OF THE NEWLY BORN. 

In jaundiced infants who have died from accident or other causes the 
skin and almost all the internal organs are found icteric. There is also 
staining of the internal coat of the arteries, the endocardium, the peri- 
cardium, and the pericardial fluid. Sometimes the subcutaneous connect- 
ive tissue is yellow, also the brain and cord ; the spleen and kidneys only 
in the most severe cases. In the kidneys uric-acid infarctions are often 
found, and sometimes bile pigment. The liver is rarely discoloured. The 
bile-ducts are normal. In certain cases Birch-Hirschfeld has discovered 
bile pigment in the liver cells. 

This jaundice is never fatal, and is not serious. Other conditions, 
such as atelectasis, may coexist, which may make the case grave. The chief 
point in diagnosis is not to confound physiological icterus with that de- 
pending upon other more serious conditions, such as sepsis or congenital 
malformation of the bile-ducts. In sepsis other symptoms are present, 
usually an abnormal condition of the umbilicus, and the symptoms ap- 
pear at a later date. In malformation of the bile-ducts the jaundice 
is very intense, and is frequently accompanied by marked hepatic en- 
largement. 

Physiological icterus requires no treatment. 



CHAPTER IV. 
THE ACUTE INFECTIOUS DISEASES OF THE NEWLY BORN. 

It is possible for the newly-born infant to suffer from almost all of the 
common infectious diseases. Smallpox probably has been most frequently 
observed. In rare instances measles, influenza, typhoid fever, malaria, 
and pneumonia have occurred in the first days of life. As the mothers 
in many instances were suffering from the diseases during or just prior to 
delivery, the infants appear to have been infected before birth through the 
circulation of the mother. In other cases, especially in pneumonia and 
influenza, infection may take place soon after birth. The symptoms of 
these diseases in the newly-born differ little from those occurring in any 
young infant. The prognosis, however, is very much worse on account of 
the tender age and feeble resistance of the patient. 

In addition to the diseases mentioned, there are other forms of infec- 
tion which belong especially — some of them exclusively — to the newly- 
born. We shall consider : (1) The Pyogenic Diseases, which are due to 
the entrance of pyogenic germs ; in this class are to be included Ophthal- 
mia and Erysipelas ; (2) Tetanus ; and (3) diseases probably infectious, but 
as yet not proved to be so — Acute Fatty Degeneration, Epidemic Hemi- 
globinuria, and Pemphigus. 



THE ACUTE PYOGENIC DISEASES. 79 



THE ACUTE PYOGENIC DISEASES. 

This group of diseases — sometimes called puerperal fever or sepsis in 
the newly-born — presents a great variety of symptoms and lesions. They 
have, however, the one feature in common, viz., that they result from the 
entrance of pyogenic bacteria* into the body of the child. The two 
micro-organisms most frequently causing the suppurative processes are 
the staphylococcus pyogenes aureus and the streptococcus. These are 
probably the exciting cause of four-fifths of the cases. The remainder 
are due to one or more of the other bacteria which cause suppuration. 
The germs may be found alone, or they may be associated with others. 
In the investigations made thus far the streptococcus has been most fre- 
quently found. This was discovered by Prudden in the dust of a ward in 
the New York Infant Asylum, where several cases had occurred, also in 
an umbilical abscess, and in the pseudo-membranous sore throat of one 
of the cases. Of a group of three cases, all occupying the same bed at the 
Sloane Maternity Hospital, one was studied bacteriologically by Prudden, 
and showed only streptococci. A case of meningitis occurring in the 
same hospital was studied by Van G-ieson, who found in cultures from the 
exudate only streptococci, which were also present in the umbilical vessels. 
The streptococcus was discovered by Allard in cases of osteomyelitis. In 
three recent cases of my own, all with multiple joint suppuration, the 
staphylococcus was found in two and the streptococcus in one — in every 
case in pure culture. The severity of the symptoms depends somewhat 
upon the nature of the bacteria which excite the disease, the form being 
usually milder when due to the staphylococcus than when due to the 
streptococcus. Still more important, however, is the degree of virulence 
of the bacteria at the time of infection. Thus the streptococcus sometimes 
excites only a very mild, and at others a most violent inflammation. 

Most frequently the avenue of entrance is the umbilical wound. This 
obtains probably in four fifths of the cases. It may be through an abra- 
sion of the skin, such as often exists about the anus or genitals, through a 
wound about the scalp or body inflicted during instrumental delivery, 
through erosions of the mucous membrane of the mouth, or through the 
eyes. Infection through the milk is denied by some writers. Although it 
has been shown that in a great proportion of the cases the milk of a 
woman suffering from mastitis or from septicasmia contains pyogenic 
germs, still the taking of these into the stomach is very unlikely to in- 

* There were formerly described cases of " septicaemia " in the newly born ; but re- 
stricting this term to its present significance — an infection due to bacterial products 
only — septicaemia is of doubtful occurrence at this period, unless we include as such 
some of the forms of diarrhceal disease. The cases of "sepsis" in the newly-born 
studied by modern methods have shown with great uniformity the presence of pyo- 
genic bacteria. 



SO DISEASES OF THE NEWLY BORN. 

feet the infant. Karlinski has reported a fatal case, in which the 
milk appeared to be the means of infection, and by experiments on ani- 
mals he proved the possibility of infection in this manner. Bacteria may 
be aspirated during or after labour, giving rise to septic pneumonia. The 
source of the poison may be other septic cases in an institution, either 
among infants or mothers. It may be carried by the physician, the nurse, 
the instruments, or the dressings. 

Infection through the umbilicus may occur either before or after the 
separation of the cord. The poison may enter through the umbilicus, 
although this may give no external evidence of disease. This was true 
in a case recently studied by Van G-ieson, in which the infant died of 
meningitis when eight days old. The cord had healed properly, and at 
the autopsy the navel appeared normal. It was accidentally discovered 
that the umbilical vessels inside the body contained pus. From this the 
meningitis evidently arose, as the same bacteria were found by culture 
both there and in the brain. Entering through the mouth, bacteria may 
lead to infectious processes in the throat, or spreading downward may 
involve the stomach and intestines, rapidly producing death ; or the ali- 
mentary tract may be the focus from which infection of distant parts may 
arise. 

Clinical Varieties. — Omphalitis. — In this variety there is inflammation 
of the umbilicus, and cellulitis of the abdominal wall . in the immediate 
neighbourhood. This results in the formation of an umbilical phlegmon. 
It may terminate in resolution, in abscess, or in gangrene. The usual 
termination is in abscess. These abscesses may be small and superficial, 
or they may be more deeply seated between the abdominal muscles and 
the peritoneum. Omphalitis usually begins in the second or third week 
of life, before the umbilicus has cicatrized. Locally there are redness, 
swelling, and induration. The process may result in abscess, there may 
be diffuse inflammation of the abdominal walls of an erysipelatous char- 
acter with extensive sloughing, or the infection may spread to the peri- 
toneum. 

Inflammation of the umbilical vessels. — This is one of the most fre- 
quent primary processes in pyaemic infection. The umbilical arteries are 
more frequently involved than the vein. According to Runge, inflamma- 
tion of the vessels is always preceded by inflammation of the connective 
tissue which surrounds them, as the poison is taken up by the lymphat- 
ics and not by the blood-vessels. Omphalitis is frequently present, but in 
some cases the umbilicus shows nothing abnormal. 

In arteritis the vessels may be involved to any degree : sometimes 
only a short distance from the abdominal wall, sometimes quite to the 
bladder. . They contain pus, and often septic thrombi. Saccular dilata- 
tion is frequently present at several points. Pus sometimes exudes from 
the umbilical stump on pressure. The other lesions accompanying arteritis 



THE ACUTE PYOGENIC DISEASES. 81 

are those of pyaemic infection, more or less widely distributed. There are 
frequently peritonitis, suppuration of the joints, erysipelas, multiple ab- 
scesses of the cellular tissue, sometimes suppurative parotitis. Atelectasis 
is common. Pneumonia was found in twenty-two of Kunge's fifty-five 
cases. 

In cases of phlebitis, the umbilical vein is usually involved for its entire 
length from the abdominal wall to the liver. This may lead to an acute 
interstitial hepatitis going on to suppuration, or to phlebitis of the portal 
vein and some of its branches. In either case there is more or less paren- 
chymatous hepatitis, and often multiple abscesses of the liver, most of the 
patients being jaundiced. Peritonitis also is a frequent complication. 

Peritonitis. — This is one of the most frequent pathological processes 
in pyaemic infection, and is very often the cause of death. It is generally 
associated with umbilical arteritis, and often with erysipelas. In a con- 
siderable number of cases it is the most important lesion found. It may 
be localized or general. Localized peritonitis is generally in the neigh- 
bourhood of the umbilicus or of the liver. It may result in adhesions, or 
in the formation of peritoneal abscesses. More frequently the peritonitis 
is general, and resembles the septic peritonitis of adults. There is a great 
outpouring of lymph coating the intestines and other viscera and the 
inner surface of the abdominal wall, causing adhesions between the ab- 
dominal contents. Collections of sero-pus are found in the pelvis and in 
various pockets formed by the adhesions. Sometimes blood is present in 
the exudation. 

The special symptoms which indicate peritonitis are vomiting, abdomi- 
nal tenderness and distention, and protrusion of the umbilicus. The ab- 
dominal enlargement is chiefly from gas, but may be partly from fluid. 
There are present thoracic respiration, dorsal decubitus, and flexion of 
the thighs as in all varieties of acute peritonitis. The temperature is 
usually high. 

Pneumonia. — The most common form seen is pleuro-pneumonia. 
There is an abundant exudate of grayish-yellow lymph covering the 
lung. Occasionally collections of pus are found in the sacs formed by 
the adhesions. Serous effusions are rare. The pulmonary lesion con- 
sists usually in a broncho-pneumonia, with consolidation of larger or 
smaller areas in the lungs — more often in the upper than in the lower 
lobes. It is not uncommon for minute abscesses to be found in the lung 
at various points. There is a purulent bronchitis of the larger and 
smaller tubes. 

The symptoms are obscure and often indefinite. The only character- 
istic ones are cyanosis and rapid respiration, with recession of the chest 
walls on inspiration. The physical signs are inconstant and uncertain. 
Pneumonia cannot usually be diagnosticated during life. In most of the 
fatal cases of pyogenic infection, whatever its type, there is found some 
8 



82 DISEASES OF THE NEWLY BORN. 

involvement of the lungs. The changes are most extensive in cases in 
which the serous membranes are involved. 

Pericarditis is rare and usually associated with pleurisy. Endocar- 
ditis is very rare. Hirst has, however, reported a case. 

Meningitis. — The pia mater is the least liable to be affected of all the 
serous membranes, with the possible exception of the pericardium. When 
meningitis is present it is usually associated with peritonitis or with 
pleurisy. The lesions are those of acute purulent meningitis with a 
copious exudation, sometimes associated with meningeal haemorrhages, 
or with acute encephalitis and the production of multiple minute ab- 
scesses in the cortex. The local symptoms are usually not marked, and 
are sometimes very obscure. The most characteristic are stupor, strabis- 
mus, dilated pupils, opisthotonus, bulging fontanel, convulsions, and occa- 
sionally .localized paralyses. The temperature is generally high. 

Gastro-enteritis. — Diarrhoea is a frequent symptom in all septic cases, 
constipation being rarely present. In many instances vomiting is a promi- 
nent symptom. In a small proportion of cases the most important local 
lesions are in the intestines, generally in the nature of a superficial 
catarrhal inflammation. 

Pseudo-membranous inflammations of the throat. — These are rarely 
seen in the newly-born. In 1888 J. Lewis Smith made a report on a 
group of five cases occurring as a small epidemic in the New York 
Infant Asylum. They were associated with other lesions, and all were 
fatal. In several cases there was omphalitis. One of these was studied 
biologically by Prudden, who found no Loeffler's bacilli, but streptococci 
both in the exudation in the throat and in the umbilical abscess. The 
streptococcus was cultivated from the dust of the ward, and it is probable 
that this was the nature of the infection in all the cases. These throat 
inflammations are to be regarded as one manifestation of a general strep- 
tococcus infection. 

Osteomyelitis. — Allard* has reported a series of cases in which, after 
the general and local symptoms of pyogenic infection had existed for some 
time, suppuration occurred over various bones, especially the humerus, 
tibia, metatarsal bones, sacrum, etc. Trephining revealed the lesions of 
osteomyelitis. The abscesses usually made their appearance between the 
fourth and the sixth week. The most rapid case died on the fourteenth 
day, and none lasted more than two-and-a-half months. 

Joint suppuration. — In certain pyaemic cases, and in some in which 
there are no other symptoms, acute suppuration in the joints occurs with- 
out any change in the bones themselves. This may come on very acutely 
in the first or second week, or more slowly as late as the third or fourth 
week. A single joint may be involved, or at times almost every articula- 

* These, Paris, 1890. 



THE ACUTE PYOGENIC DISEASES. 83 

tion in the body. I have recently seen four cases of this kind. . In one, 
a shoulder and one temporo-maxillary articulation were involved ; in 
another, a shoulder and hip ; in the remainder there were multiple lesions 
affecting nine or ten joints, including the elbow, ankles, and sterno-clavic- 
ular joints, together with the wrists, fingers, and toes. 

Abscesses in the cellular tissue. — These are quite frequent, and may 
occur with suppuration in the joints or internal organs, or they may exist 
as the only lesion. They may be found where the adipose tissue is scanty, 
as over the heels, the elbows, and the malleoli ; also in the thighs, the 
ischio-rectal region, and sometimes in the abdominal walls. They are 
nearly always multiple. They vary in size from that of a small pea to one 
containing half an ounce of pus. They are due to the introduction of 
pyogenic germs, usually staphylococci. Their course is benign, and they 
require no treatment except incision and cleanliness. Where there is a 
disposition to their continued formation, the skin should be washed with 
an antiseptic solution. 

Erysipelas. — This is seen especially during the first two weeks of life, 
and most frequently starts from the umbilicus, although it may follow any 
wound or abrasion of the skin. When originating at the umbilicus it is 
generally complicated by other lesions, such as peritonitis and umbilical 
phlebitis. If it start from any other part of the body it may be uncom- 
plicated. It is now pretty well agreed among bacteriologists that the 
difference between the streptococcus pyogenes and the streptococcus of 
erysipelas is in the degree of their virulence. While we have the two 
extremes well marked — typical erysipelas on the one hand, and sim- 
ple cellulitis terminating in a circumscribed suppuration, on the other — 
we have all the intermediate grades of severity between them. 

Erysipelas starting at the umbilicus gives rise to an area of indura- 
tion, with a redness which is quite sharply circumscribed. It may be 
superficial, or it may involve the deeper tissues. It may terminate in 
diffuse suppuration or in gangrene. The erysipelas of the newly-born 
tends to spread with rapidity, often extending over nearly the whole 
trunk. The general symptoms are great prostration, high temperature — 
from 102° to 105° F. — localized pain and tenderness, great restlessness, 
wasting, vomiting, and diarrhoea. The disease is always serious, and when 
starting from the umbilicus usually fatal. The prognosis is better in cases 
originating elsewhere, but under all conditions the disease is a very seri- 
ous one. 

Distribution of the Lesions. — The frequency of the different visceral 
lesions in eighty-seven autopsies published by Bednar was as follows : 
Peritonitis in twenty-nine, pneumonia in fifteen, pleurisy in ten, menin- 
gitis in nine, meningeal haemorrhage in eight, encephalitis in eight, cere- 
bral haemorrhage in four, entero-colitis in five, pericarditis in four. In 
thirty-one cases there was umbilical arteritis, and in nine cases umbilical 



84 DISEASES OF THE NEWLY BORN. 

phlebitis. There was one case each of pulmonary haemorrhage, pleural 
haemorrhage, acute hydrocephalus, acute bronchitis, and suppuration in 
the cellular tissue. Kunge's later observations of thirty-six cases showed 
umbilical arteritis in thirty, umbilical phlebitis in three, and normal um- 
bilicus in three. He found pneumonia in twenty-two of fifty-five cases. 
Other lesions frequently associated are atelectasis, swelling and softening 
of the spleen, cloudy swelling of the liver and kidneys, occasionally with 
foci of suppuration in these organs. The blood is dark, and coagulates 
imperfectly. 

General Symptoms. — These may begin at any time during the first ten 
days — very rarely after the twelfth day. Fever is an exceedingly variable 
symptom — it may be very high ; it may be almost absent ; occasionally 
there is subnormal temperature. The course of the temperature is very 
irregular. Wasting is constant and quite rapid. It depends upon the 
inability to take and digest food, upon the intestinal complications, and 
upon infection. In quite a number of cases wasting is almost the only 
symptom. Icterus is exceedingly common ; in many of the worst cases 
it is intense. It is met with where the liver is the seat of an acute paren- 
chymatous or acute suppurative inflammation, and in many other cases 
where it depends apparently upon the blood changes. Haemorrhages are 
common, and may be the direct cause of death. They are most frequent 
from the umbilicus, from the intestine, and into the subcutaneous cellu- 
lar tissue. They may occur in almost any organ or from any mucous 
membrane. Nervous symptoms are generally present, and are sometimes 
marked. They are restlessness, rolling of the head, a constant whining 
cry, twitchings of the muscles of the extremities or face, stiffening of the 
body, more rarely general .convulsions. Late in the disease, dulness and 
stupor are present. The pulse is rapid and weak and the respirations are 
often irregular even when there is no cerebral complication. Diarrhoea is 
frequent ; the stools are green, brown, sometimes black from the presence 
of blood, and are often very foul. Vomiting is less common. 

In addition to these there are symptoms due to the various forms of 
local inflammation — peritonitis, meningitis, pneumonia, subcutaneous sup- 
puration and gangrene, these all being found in varying degrees and in 
various combinations. 

Prophylaxis. — Isogenic infection of the child, like puerperal fever in 
the mother, may be considered a preventable disease. Its occurrence is 
usually due to a failure to carry out proper rules regarding cleanliness and 
asepsis in connection with delivery. The statistics of the Moscow Lydng- 
in Asylum, published by Miller in 1888, show that previous to the general 
introduction of antiseptic methods, from six to eight per cent of all in- 
fants born in the institution died from some variety of infection. In 
twenty-three hundred successive labours at the Sloane Maternity Hospital, 
in New York, up to January, 1893, not a single marked case occurred. 



OPHTHALMIA. §5 

From these figures it will be evident that in the vast majority of cases 
the occurrence of a case of infection of a serious nature, is the fault of the 
physician or nurse in attendance. 

The umbilicus should be cleansed and treated like any other fresh 
wound. Dry dressing should invariably be employed, and antiseptic 
gauze or salicylated cotton in preference to household linen. If suppu- 
ration occurs at the time the cord separates, the parts should be cleansed 
daily with 1-3,000 bichloride solution, and powdered with iodoform. All 
wounds of the face, scalp, and other parts should be treated in the same 
way. The ligatures and everything which comes in contact with the um- 
bilical wound should be sterilized. Careful attention should be given to 
the mouth, genitals, and all the muco-cutaneous surfaces, to prevent ex- 
coriations and intertrigo. Finally, every septic case occurring in an insti- 
tution should be immediately isolated. A nurse in charge of a septic 
woman should not have the care of the infant. 

Prognosis, — Pyogenic infection in the newly born, even in its mildest 
forms, is a serious disease, and in its severer forms is almost invariably 
fatal. Few cases recover in which there is present any form of visceral 
inflammation. 

Treatment. — The treatment of cases of pyogenic infection practically 
resolves itself into the treatment of individual symptoms as they arise. 
Wherever suppuration occurs, external abscesses should be evacuated and 
treated antiseptically. For the local inflammations of the lungs, peri- 
toneum, and brain, little or nothing can be done in the way of direct 
treatment. The condition is one to be prevented, but not cured. The 
general indications are to sustain the patient by proper feeding and the 
use of stimulants whenever required by the pulse. For local use in ery- 
sipelas, nothing, in my experience, is better than a ten-per-cent ointment 
of ichthyol made up with lanoline, kept constantly applied. When 
affecting only one of the extremities, the treatment by the Kraske method, 
of making scarifications beyond the line of redness and covering with wet 
bichloride dressings, is sometimes successful, but this is not applicable to 
cases involving the trunk. 

OPHTHALMIA. 

Ophthalmia of the newly-born is to be classed among the pyogenic dis- 
eases. It usually consists in a purulent conjunctivitis. In the more severe 
cases there may be ulceration of the cornea, and even perforation into the 
anterior chamber of the eye. 

The infectious nature of this ophthalmia is now fully established. In 
the most severe cases the micro-organism generally found has been the 
gonococcus; but in the milder forms the gonococcus is absent, and any 
of the common pyogenic germs may be found. In the gonorrhoeal cases 
the infection occurs during labour from the secretions of the mother, 



86 DISEASES OF THE NEWLY BORN. 

from the examining fingers of the physician, or from instruments ; or 
after birth from infected cloths and other materials which come in con- 
tact with the eye. Healthy lochia produce only a catarrhal inflammation. 
The infection occurring after birth may take place at any time. That 
due to gonorrhoeal infection from the mother is generally manifested on 
the third day, and is often violent from the outset. 

The symptoms are swelling of the lids, chemosis, copious purulent dis- 
charge, sometimes haemorrhages from the lids, ulceration and there may 
even be sloughing of the cornea. The course of the disease depends upon 
the cause and upon the treatment employed. In the cases not due to 
the gonococcus the course is generally benign, and with ordinary cleanli- 
ness usually results in recovery without any permanent damage to the 
sight. The gonorrhoeal cases, unless energetically treated from the outset, 
are very frequently followed by permanent loss of vision. The best sta- 
tistics upon the causes of blindness in adults show that from twenty-six 
to thirty per cent of such cases are due to ophthalmia in the newly-born. 
This disease is occasionally complicated by other symptoms of gonorrhoeal 
infection of a pysemic nature. Widmark, Lucas, and Davies-Colley have 
reported cases followed by acute articular symptoms. 

Prophylaxis is of the utmost importance. Crede's statistics show that 
in 1874 the frequency of ophthalmia in his lying-in hospital was 13'6 per 
cent. In the three years ending 1883, among 1,160 newly-born children 
only one or two cases occurred. The method of prophylaxis which he 
adopted consists in dropping into the eyes of every child, immediately after 
birth, one or two drops of a two-per-cent solution of nitrate of silver. 
The general adoption of Crede's method, or of some similar means of dis- 
infection, has resulted in a very great diminution in the frequency of oph- 
thalmia throughout the world. These prophylactic means should be 
obligatory in all institutions, and should be used in all cases in private 
practice wherever there is any possible suspicion of the existence of gon- 
orrhoea. In all other cases the eyes should be carefully cleansed with a 
saturated solution of boric acid. The use before delivery of an antiseptic 
vaginal douche is theoretically indicated, but practically it has been found 
to be inadequate to the prevention of the disease. 

Treatment. — Everything which comes in contact with the eyes should 
be carefully disinfected. All cloths, cotton, etc., used for cleansing should 
be immediately burned. The strictest antiseptic precautions should be in- 
sisted on to prevent the spread of the infection by nurses. In institutions 
containing infants, severe cases of ophthalmia should always be isolated. 
The most important thing is to keep the eyes clean. In severe cases they 
must be cleansed every twenty minutes, night and day. It is best accom- 
plished by means of an eye-dropper with a slightly bulbous tip, inserted 
alternately at the inner and the outer angle of the eye, and the fluid in- 
jected with force sufficient to empty thoroughly the conjunctival sac. For 



TETANUS. 87 

this purpose a saturated solution of boric acid, or a 1-5,000 solution of bi- 
chloride, may be employed, the important feature being that the eye be 
cleansed thoroughly, and so frequently that the pus is never allowed to 
accumulate. Once or twice in twenty-four hours two or three drops of a 
one-per-cent solution of nitrate of silver should be put into the eye ; or a 
stronger solution may be employed and immediately neutralized with a 
salt solution. The next most valuable means of treatment is cold. Ice- 
cold compresses should be employed for thirty minutes every two hours 
in the milder cases, while in the most severe ones they must be used con- 
tinuously. These should be cooled by placing them on a block of ice, and 
changed at least every minute, so that they are kept cold. If the cornea 
is involved the pupil should be kept dilated by means of atropine, and this 
is wise in all severe cases. 

TETANUS. 

Tetanus is an acute infectious disease characterized by tonic muscular 
spasm, which increases in severity by paroxysms occurring at longer or 
shorter intervals. It may be limited to the muscles of the jaw (trismus), 
or may affect all the muscles of the trunk, extremities, and neck. 

Though many writers have sought to maintain a difference between 
tetanus of the newly-born and tetanus of later life, whether traumatic or 
not, their identity has been admitted for at least a dozen years. The dis- 
covery of the exact cause of tetanus is due to the work of Nicolaier, who 
in 1884 found a bacillus in the soil, with which he produced the disease in 
animals. He demonstrated the presence of this bacillus in the wounds of 
tetanus patients. Nicolaier did not, however, obtain the germ in pure 
culture ; but this was done by Kitasato in 1889. The bacillus is generally 
known as Nicolaier's bacillus. Since that time the germ has been found 
in the wounds of numerous patients with tetanus, including newly-born 
infants. 

The rapidity with which the infection spreads from the point of inoc- 
ulation is very remarkable, as shown by Kitasato's experiments. Thus, if 
one hour elapsed after infection before cauterizing the inoculated wound, 
the animal succumbed to the disease. The bacilli are not found in the 
blood or internal organs. The symptoms of the disease have been shown 
to depend upon the absorption of a toxic product of the tetanus bacillus 
called tetano-toxine. 

The germ of tetanus usually gains access to the body of the infant 
through the umbilical wound. It exists in the soil, and the disease pre- 
vails endemically in certain localities. It is common in certain parts 
of Long Island and New Jersey. Among the negroes in some parts of 
the South it has for many years occurred with great frequency. It is 
stated that on one of the islands of the Hebrides every fourth or fifth 
child dies of tetanus. In a single house in Copenhagen eighteen cases 



88 DISEASES OF THE NEWLY BORN. 

were observed. Tetanus is rare except where dirt and filth prevail; but 
these alone are not sufficient to produce the disease. It is a very rare dis- 
ease in the tenements of New York. 

Lesions. — There are no essential lesions of tetanus. Those which have 
been found have been partly accidental and partly a result of the disease 
rather than its cause. In most of the cases intense hyperemia of the 
spinal cord and its membranes is found, and not infrequently small ex- 
travasations of blood. Such small haemorrhages are occasionally found in 
the meninges of the brain — more frequently at the base than at the con- 
vexity. In rare instances haemorrhages of considerable size have occurred 
into the brain itself. The lungs are generally congested, and the right 
side of the heart overdistended. In most of the cases the umbilicus has 
not healed, and it may present evidences of septic infection in varying 
degrees. 

Symptoms. — These, as a rule, begin on the fifth or sixth day, or at 
the time of the separation of the cord. The first symptoms may not 
appear until the tenth or twelfth day, but rarely later than this. Gen- 
erally the first thing noticed is difficulty in nursing, which, on examina- 
tion, is found to be due to rigidity of the jaws (trismus). Nursing may 
be impossible on this account. The muscles of the jaw feel hard, the lips 
pout and all the muscles of the face seem firm. Soon a slight stiffening 
of the body occurs, the child straightening the back as it lies upon the 
lap and continuing rigid for a moment or two. In the interval it is at 
first completely relaxed. These paroxysms soon increase in frequency 
until they may come on every few minutes, being excited by any move- 
ment of the body. The relaxation is then only partial, and the neck and 
extremities, sometimes nearly the whole body, become rigid and stiff as a 
piece of wood. The arms are extended, the thumbs adducted, and the 
hands clenched. The thighs and legs are extended, and no motion is pos- 
sible at the hip or knee. The jaws can be separated slightly or not at all. 
The firm contractions of the facial muscles give a peculiar expression to 
the features. There is a low, whining cry. Swallowing is difficult, some- 
times impossible. The pulse is rapid and soon becomes weak. The tem- 
perature at first is normal, but in the most acute cases rises rapidly to 104° 
or even 106° ; in the milder cases it does not go above 101° F. 

Death is due to exhaustion, to fixation of the respiratory muscles, or 
to spasm of the larynx. In the less severe cases all the symptoms are* 
milder, and there may be intervals in which the rigidity is scarcely notice- 
able, so that respiration and deglutition may be carried on for some time. 
In cases which terminate in recovery the temperature is but slightly ele- 
vated. The tonic contractions gradually become less severe, and the 
paroxysms less frequent. The children usually suffer for several weeks 
from the general symptoms of malnutrition, which are proportionate to 
the severity of the attack. Of eighty-eight fatal cases which are reported 



TETANUS. 89 

by Stadtfeldt all but five died between the ages of six and ten days. The 
duration of the disease in the fatal cases is seldom more than forty-eight 
hours, often less than twenty-four hours ; in those terminating in recov- 
ery, between one and three weeks. 

Prognosis. — No disease of infancy is more fatal than tetanus. Where 
it prevails endemically it is regarded by the laity as so uniformly fatal that 
usually no physician is called. Scattered through medical literature are 
quite a large number of isolated cases in which recovery has occurred. At 
the present time the proportion of fatal cases is probably between ninety 
and ninety-five per cent. Sporadic cases more frequently recover than 
those occurring in districts where the disease is endemic. The later the 
development of the symptoms, the slower their course, and the lower the 
temperature the more likely is the case to recover. 

Prophylaxis. — A proper understanding of the nature of the disease has 
brought with it the means of rational prevention. The first essential is 
obstetrical' cleanliness, which must include scissors, hands, dressings, liga- 
tures — in short, everything which comes in contact with the umbilical 
wound. In districts where tetanus is endemic, thorough antiseptic treat- 
ment of the umbilicus should be insisted upon, both at the first dressing 
and later, particularly at the time of the separation of the cord. 

Treatment. — All drugs whose physiological action is that of motor 
depressants of the spinal cord have a certain amount of value in tetanus. 
The most important ones are chloral, the bromides, and calabar bean. 
Nearly all the reported cures have been by one of these drugs or a com- 
bination of them. The mistake usually made is in using too small doses 
to be of any efficacy. Enough to produce the physiological effects of the 
drug must be given. The initial dose should not be large, but it should 
be repeated until the full effects are obtained. Of those mentioned, chloral 
has been the one most generally relied upon. An hourly dose of one or 
two grains is usually required. If no effect is visible in ten or twelve 
hours the dose may be further increased, as the patient is in much greater 
danger from the disease than he can possibly be from the drug. Chloral 
may be given by the mouth or by the rectum, but must always be well 
diluted. The single case of recovery which I have witnessed was one 
treated by the bromide of potassium. This infant took eight grains every 
two hours for three days, afterwards smaller doses. Calabar bean has the 
advantage in that its extract may be given hypodermically ; one tenth of 
a grain may be administered from three to ten times daily, according to 
the severity of the symptoms. Monti has reported two cases cured by 
its use. The child must at all times be kept as quiet as possible, without 
unnecessary handling or bathing. If nursing or feeding by the mouth is 
impossible, because the jaws cannot be separated, the child may be fed 
by a tube passed through the nose. This is greatly to be preferred to 
rectal alimentation. Drugs may be administered in the same way. 



90 DISEASES OF THE NEWLY BORN. 

The antitoxine treatment. — B.ehring and Kitasato, after a series of 
experiments upon animals, have produced a substance called tetanus 
antitoxine which has the power of neutralizing the tetanus poison. In 
animals immunity is produced by its injection. It is also curative 
in those cases where tetanus has been induced artificially. As yet 
the number of cases in which this treatment has been applied to man 
is too small to admit of positive deductions regarding its value. The 
practical difficulties in applying it are great, because of the very rapid 
absorption of the tetanus poison from the wound. The treatment is not 
efficient unless it is adopted very early in the disease. This is not always 
easy, as cases are not common. In Italy, ten cases, chiefly of traumatic 
tetanus, have been reported cured by the antitoxine ; but experience else- 
where has not been quite so satisfactory. In England, two cases of trau- 
matic tetanus have been cured by the injection of the serum. Escherich 
has recently reported (1894) four cases of tetanus in the newly-born treated 
by antitoxine, with one recovery, the symptoms of this case diminishing 
rapidly after the second injection. Papiewski treated three cases by this 
method, two of which recovered, but the course was such that the result 
could hardly be attributed to the antitoxine. The most reliable anti- 
toxine at present in the market is that of Behring. It is prepared from 
the serum of the horse, and sent out in a dried state, to be dissolved in 
water and injected subcutaneously. 

EPIDEMIC HEMOGLOBINURIA (WINCKEL'S DISEASE). 

The essential features of this disease are hemoglobinuria with icterus 
and cyanosis, this combination giving the skin a deeply bronzed hue (mala- 
die bronzee). It is a rare disease, but has generally occurred epidemically 
in institutions. It is usually fatal. All the symptoms point to an acute, 
rapid disintegration of the red blood-cells — a sort of blood fermentation. 
The changes have been compared with those produced in the blood in 
poisoning by chlorate of potash or phosphorus. The cause is, without 
doubt, some sort of infection, but its exact nature has not been discovered. 
Although generally called by the name of Winckel,* who in 1879 made a 
full report upon an epidemic of twenty-three cases in a hospital in Dres- 
den, the disease was quite well described by Charrinf in 1873, with a 
report of fourteen cases, and observed by Bigelow,J; in Boston, in 1875. 
All the cases included in Winckel's report occurred in one institution, 
affecting one fourth of the children born during the period. 

There are cyanosis, and a more or less intense icterus of the skin and 



* Winckel, Veroffentlich. der padiatrischen Section der Gesellsch. f. Heilk., Berlin, 
April, 1879. 

f Charrin, These de Paris, 1873. 

% Bigelow, Boston Medical and Surgical Journal, March, 1875. 



FATTY DEGENERATION. 91 

internal organs. The umbilical vessels are usually normal. The kidneys 
are swollen, show small haemorrhages into their substance, and under the 
microscope the straight tubes are seen to be filled with crystals of haemo- 
globin, but contain no blood-cells. The bladder frequently contains 
brownish, smoky urine. The spleen is swollen and filled with blood pig- 
ment, which is diffused throughout the cells of the pulp, and free in the 
blood-vessels. Punctate haemorrhages are seen in most of the other vis- 
cera. Fatty degeneration is at times observed in the heart and liver. 
Peyer's patches and the mesenteric glands are frequently swollen. 

This disease most frequently attacks those who have been previously 
healthy. The symptoms usually begin from the fourth to the eighth day 
after birth. They are intense and fulminating in character, seldom lasting 
more than two days, and often only one. The early symptoms are general 
restlessness, rapid pulse and respiration, prostration, c} T anosis of the face, 
and general icterus, which is at first slight, but steadily increases until it 
becomes intense, the skin resembling that of a mulatto. The temperature 
is normal or slightly elevated. Gastro-enteric symptoms are occasionally 
present, but they are not a feature of this disease. There is rapid asthenia, 
often terminating in coma or convulsions. The most characteristic symp- 
toms are those connected with the urine. It is passed frequently, in small 
quantities, with pain and straining. It is of a brown, smoky color, and 
under the microscope shows haemoglobin in considerable quantity, renal 
epithelium, and sometimes granular casts and blood-cells, but does not 
contain bile pigment. Albumin is sometimes present, but not in large 
quantity. Examination of the blood shows an increase of the white cells 
and many free granules. 

Treatment is of little avail, since all severe cases die. It is to be 
directed against individual symptoms. 

FATTY DEGENERATION OF THE NEWLY BORN (BUHL'S DISEASE). 

A disease has been described by the author whose name it bears, the 
essential nature and causation of which are unknown. It is character- 
ized by inflammatory changes leading to fatty degeneration in the viscera, 
especially the heart, liver, and kidneys ; it seldom lasts more than two 
weeks, and is almost invariably fatal. There may be haemorrhages in any 
of the viscera, into the serous cavities, or from any mucous membrane. 
In the lungs are found large or small hemorrhagic infarctions, and the 
bronchi contain blood and bloody mucus. There is granular or fatty de- 
generation of the epithelial cells of the alveoli. In cases that have lasted 
some time, the heart-muscle is pale, soft, and fatty. The liver in re- 
cent cases is large and soft; in those of longer standing it is pale and 
jaundiced, and shows marked fatty degeneration. The spleen is large 
and soft. The stomach and intestines contain blood, and the mucous 
membrane shows ecchymoses. The epithelium of the tubules of the 



92 DISEASES OP THE NEWLY BORN. 

kidney is fatty, and the tubes are choked with granular and fatty detri- 
tus. The umbilicus is normal, but often there are haemorrhages into the 
neighbouring tissues. Many of the lesions are similar to the ordinary 
post-mortem changes, and when found they should not be interpreted as 
pathological unless the autopsy has been made within at least twelve hours 
after death. 

The disease occurs most frequently in patients who have previously 
presented the symptoms of asphyxia, which to a greater or less degree 
have persisted. In other respects the infants may be strong and well- 
nourished. The symptoms develop gradually. Those most constantly 
present are vomiting of blood, bloody stools, icterus, and oedema which 
may affect only the dependent parts, or may be general. When the cord 
separates there is often bleeding at the umbilicus. The constitutional 
symptoms are prostration, rapid loss in weight, and all the evidences of 
malnutrition. There is no appreciable rise in temperature. External 
haemorrhages may be wanting altogether. Death occurs from progressive 
asthenia or haemorrhage. The clinical features resemble those of pyogenic 
infection, but in Buhl's disease the umbilicus is healthy, aside from occa- 
sional haemorrhages, and there is no rise of temperature. The disease 
occurs in isolated cases, not in groups. The treatment is entirely symp- 
tomatic. 

PEMPHIGUS. 

Pemphigus is a term used to designate a lesion rather than a disease. 
By it is meant an eruption of bullae occurring usually upon a red base, 
the contents being in most cases clear serum. The term has been made 
in the past to include several different diseases even in the newly-born. 

1. Traumatic pemphigus is a condition which has been induced by 
putting infants into very hot baths. 

2. Pemphigus is seen as one of the lesions of congenital syphilis. In 
these cases the eruption is often present at birth. It rarely appears after 
the fourteenth day. The bullae are often seen upon the palms and the 
soles, but may be present on any part of the body. These infants are 
usually in a wretched condition, and die in a few weeks, often in a few 
days. 

3. There is a variety of pemphigus which seems clearly due to infec- 
tion. This has been observed in small epidemics in institutions. Quite a 
number of such epidemics have been seen in Europe, but none that I am 
aware of have been reported in America. Koch reports twenty-three cases 
occurring in two years in the practice of one midwife, she herself being 
probably the source of infection. The same writer states that in two cases 
the disease developed upon the breasts of mothers who were nursing af- 
fected children. While the infectious character of the disease is pretty 
generally admitted, the exact nature of the exciting cause has not } T et been 



HEMORRHAGES. 93 

determined. Strelitz discovered in the exudate two varieties of patho- 
genic cocci. Demme found diplococci. 

The clinical picture presented by this form of pemphigus is so striking 
that the disease can scarcely be mistaken. The symptoms begin in most 
cases between the third and sixth day of life. There is a bullous erup- 
tion, which appears upon the abdomen, neck, face, or thighs. It is com- 
monly seen first upon the trunk. Usually there are but ten or twenty 
bullae present ; but nearly the whole body may be covered except the 
palms and soles, where they are rarely seen. They may even appear upon 
the conjunctiva or the mucous membrane of the mouth. The single vesi- 
cles vary in size from one fourth to one or two inches in diameter. They 
are usually rounded, with a reddened base. The contents may be clear or 
cloudy. The small vesicles may coalesce and form very large bullae. Eup- 
ture usually occurs in one or two days, and there is left a moist red sur- 
face, which quickly dries. After the falling off of the crust there remains 
a red or violet patch upon the skin. The eruption may come out quite 
rapidly, almost at once, or the disease may be prolonged, the bullae appear- 
ing in crops for from one to three weeks. If ulceration occurs the dura- 
tion of the disease may be considerably lengthened. In many particulars 
the pemphigus resembles impetigo contagiosa, with which it has no doubt 
often been confounded. 

The principal point in diagnosis is to distinguish between syphilitic 
and non-syphilitic pemphigus. The latter usually occurs in well-nourished 
children, and the prognosis is good unless there are serious complications, 
which are not common. In weak or puny children the disease may be 
fatal. 

The treatment consists in absolute cleanliness, and in the use of ab- 
sorbent antiseptic powders, such as equal parts of boric acid and starch, 
to dry up the eruption, or antiseptic lotions, such as 1 to 10,000 bichloride, 
or a one-per-cent solution of ichthyol. 



CHAPTER V. 
HJEMORRHA GES. 

Hemorrhages are quite frequent during the first days of life, and are 
important not only from the fact that they are often the cause of death, 
but, when the brain is the seat, from their remote effects. There are sev- 
eral conditions in the newly-born which predispose to bleeding — the 
extreme delicacy of the blood-vessels, and the great changes taking place 
in the blood itself and in the circulation in the transition from intra- 
uterine to extra-uterine life. Haemorrhages may complicate many of the 



94 DISEASES OF THE NEWLY BORN. 

diseases of the early days of life, such as syphilis or sepsis, or they may 
exist alone. 

The cases may be divided into two groups : (1) Traumatic or Acci- 
dental Haemorrhages, which depend upon causes connected with delivery ; 
(2) Spontaneous Haemorrhages, or The Haemorrhagic Disease of the 
Newly- born. 

TRAUMATIC OR ACCIDENTAL HAEMORRHAGES. 

These are mainly due to pressure in natural labour, or to means em- 
ployed in artificial delivery, but some of them may possibly result from 
injuries received before birth. Their position is influenced by the presen- 
tation and the nature of the means employed in delivery. They are more 
frequent in large children, in difficult labours, and where from any cause 
the body of the child has been subjected to undue pressure. The most 
important of these are haematoma of the sterno-mastoid, cephalhaematoma, 
and certain of the single visceral haemorrhages, which may be intracranial, 
thoracic, or abdominal. 

Haematoma of the Sterno-Mastoid. — Haematoma, or, as it is sometimes 
called, induration of the sterno-mastoid muscle, leads to the formation of 
a tumour in the belly of the muscle. It is a rare condition, usually no- 
ticed in the second or third week of life, and it disappears spontaneously, 
without causing any permanent deformity. The tumour varies from three 
quarters of an inch to one inch and a half in length, being about the size 
and shape of a pigeon's egg. It is movable, almost cartilaginous to the 
touch, and sometimes slightly tender. The situation of the tumour is usu- 
ally about the centre of the muscle. There is no discoloration of the skin. 

In about two thirds of the cases it occurs after breech presentations. 
It is much more frequent upon the right than upon the left side. In 
twenty-seven cases collected by Henoch the right side was involved in 
twenty-one and the left in only six cases. The explanation of this differ- 
ence is to be found in the obstetrical position. Earely, both sides may 
be involved. The head is usually inclined towards the shoulder of the 
affected side and rotated towards the opposite side. The tumour is fre- 
quently discovered by accident. Often it is the slight rotation of the head 
which is first noticed. Haematoma of the sterno-mastoid is frequently 
mistaken for an enlarged lymphatic gland ; its position, however, is diag- 
nostic. The swelling slowly diminishes in size, and in most cases by the 
end of the third month has entirely disappeared. Occasionally a slight 
torticollis remains for a longer time, but in the majority of cases the re- 
covery is perfect. Haematoma of the sterno-mastoid is due to the twisting 
of the head during parturition. It is not an evidence of the employment 
of any improper violence in delivery. The twisting of the head produces 
laceration of some of the blood-vessels of the muscle, and in some eases 
there is doubtless rupture of some of the fibres of the muscle itself. Fol- 



CEPHALHEMATOMA. 95 

lowing this there occurs a certain amount of inflammation of the muscle 
and its sheath. The tumour is due partly to blood-extravasation and 
partly to inflammatory products. In one or two recent cases in which 
the sheath of the muscle has been opened it has been found filled with 
blood. Usually the inner border of the muscle is the part most affected. 

The prognosis for complete recovery is good. The condition requires 
no treatment. Operative interference is positively contraindicated. 

Cephalhematoma. — This is a tumour containing blood, situated upon 
the head, usually over one parietal bone, and tending to spontaneous dis- 
appearance by absorption. The source of the blood is the rupture of the 
small vessels of the pericranium. 

Etiology. — Cephalhematoma is sometimes due to a distinct traumatism 
like the application of forceps or to some other injury during labour. In 
the majority of cases, however, there is no evidence of such injury, and 
the cases are regarded as of spontaneous origin. Several etiological factors 
are probably present. Besides the conditions predisposing to all haemor- 
rhages, there is the increased pressure in the blood-vessels of the head 
during delivery, especially when labour is prolonged or difficult; there 
may be changes in the bone, such as an imperfect development of the ex- 
ternal table, which has been found in a few instances, and in consequence 
of which the periosteum readily separates when the head is subjected to 
the pressure of the pelvis ; and, finally, there may be changes in the blood 
itself. Cephalhematoma is a comparatively rare condition, being present, 
according to the statistics of the Sloane Maternity Hospital, in 20 of 1,300 
consecutive births, or 1-6 per cent. This is rather more frequent than is 
stated by European observers. The condition is more common after first 
labours, after difficult labours, and in vertex presentations. It occurs 
twice as often in males as in females, probably from the greater size of the 
head in male children. 

Lesions. — In the 20 Sloane cases, the situation was over the right parie- 
tal bone in 12 ; over the left in 2 ; over both parietals in 4 ; over the oc- 
cipital in 2. The location of the tumor seems to have a very close relation 
to the position of the head in the pelvis. In 8 of the right-sided cases the 
head was in the left occipitoanterior position ; in 3 it was in the right 
occipitoanterior ; in 1 case the position was unknown. Of the cases with 
occipital tumours, both were breech presentations. Of the 16 cases with a 
single tumour the labour was natural in 10, tedious in 4, and in 2 forceps 
were used. Of the 4 double cases, 2 were forceps deliveries, 1 a tedious 
labour, and but 1 was natural. 

In rare cases triple tumours are met with, one over each parietal and 
one over the occipital bone. The attachment of the periosteum along the 
sutures, usually limits the tumour to the surface of one bone. It never ex- 
tends along the sutures or over the fontanel. In cases where there is a 
more definite injury, such as the forceps, the tumour may be present over 



96 DISEASES OF THE NEWLY BORN. 

any one of the cranial bones, but more frequently over the parietal. The 
seat of the haemorrhage is between the periosteum and the cranium. The 
scalp shows punctate hemorrhages and sometimes infiltration with blood. 
In recent cases the blood is fluid ; later it is coagulated. There is often 
developed about the blood-clot a sort of cyst wall which limits its exten- 
sion. The bone is roughened, and there are at times small bony plates in 
the under surface of the periosteum. The amount of extravasated blood 
is usually from half an ounce to an ounce. In extreme cases it may be 
from four to six ounces. The cases following natural delivery are gen- 
erally uncomplicated. The traumatic cases may be complicated by ex- 
travasations between the bone and the dura (internal cephalhematoma), 
or by meningeal or cerebral haemorrhages. If there is a wound, infection 
may be followed by purulent meningitis and even by cerebral abscess. 

Symptoms. — The tumour is usually noticed from the first to the fourth 
day after birth, appearing as a slight prominence in one of the positions 
indicated. Gradually increasing in size, it attains its maximum at the end 
of a week or ten days, and then slowly diminishes. In the average case 
the tumour is about the size of a hen's egg, and is oval in form. In marked 
cases it may be one third the size of the child's head. To the touch it is 
soft, elastic, fluctuating, and irreducible. It does not increase with the cry 
or cough. There is no extra heat and no sign of inflammation. Usually 
the tumour does not pulsate, although in rare instances pulsating cephal- 
hematomata have been seen. Very soon the tumour is surrounded by a 
marginal ridge. At first this is apparently from coagulation of blood, but 
later it may be bony. The prominent ridge with the soft centre gives 
a sensation somewhat like that of a depressed fracture. Sometimes on 
pressure there is obtained a sort of parchment-crackling. This is gener- 
ally found as the swelling is subsiding, and is sometimes clearly due to the 
formation of minute bony plates upon the inner surface of the perios- 
teum. It may be found when there is nothing but thin coagula to explain 
it. In certain cases following severe traumatism, cephalhematoma may 
be complicated with wounds of the scalp, fracture of the skull, and even 
lacerations of the dura mater or the brain. In such cases the tumour 
may become inflamed, but in the spontaneous cases this is extremely rare. 
The usual signs of abscess develop, which may open externally or burrow. 
Fortunately this termination is seldom seen. 

As a rule, without any interference, the uncomplicated cases go on to 
recovery. The complete disappearance of the tumour maybe expected in 
from six weeks to three months, depending on its size ; but a hard, uneven 
elevation may remain at its site for a longer time. The cases due to severe 
traumatism are more serious, the gravity depending not upon the cephal- 
hematoma but upon the complicating lesions. 

Diagnosis. — Cephalhematoma may be confounded with encephalocele. 
This, however, occurs along the line of the sutures or at the fontanels, is 



VISCERAL. HEMORRHAGES. 97 

partly reducible, pressure causes cerebral symptoms, and frequently the 
tumour increases with respiratory movements. Hydrocephalus is distin- 
guished by the symmetrical enlargement of the head, the large frontanels, 
and the widely separated sutures. Caput succedaneum often appears in the 
same j)lace as a cephalhematoma and at the same time, but is an oedem- 
atous, not a fluctuating tumour, is not circumscribed, lacks the hard, 
marginal border, and begins to disappear by the second or third day. 
From a depressed fracture of the skull, it is differentiated by the fact that 
in cephalhaematoma there is a tumour and not a depression ; the promi- 
nent margin which is raised above the contour of the skull, is not osseous 
and the skull can be felt at the bottom of the centre of the tumour. 

The treatment in the uncomplicated cases is simply protective, all 
such cases tending to spontaneous recovery. No local or general treat- 
ment to promote absorption is required. The child should be so placed 
and so handled that no injury may be done to the affected part. Com- 
presses are unnecessary. If complications exist, such as injury to the 
bones, dura, or brain, they are to be treated in accordance with general 
surgical principles. Operative interference is called for only when sup- 
puration has occurred, or when there are brain symptoms which point to 
the existence of internal as well as external cephalhematoma. 

Visceral Haemorrhages. — While these are most frequent in large chil- 
dren and following difficult labours, they may occur in small children and 
where the labour has been easy and normal — their occurrence here being 
due to the feeble resistance of the blood-vessels. From one hundred and 
thirty autopsies upon still-born children or those dying soon after birth, 
Spencer concludes that intracranial haemorrhages are more frequent in 
head-forceps than in breech cases, and more frequent in breech than in 
natural vertex deliveries. Other visceral haemorrhages are much more 
frequent in breech cases. 

Not all visceral haemorrhages are to be classed as traumatic. They are 
often seen with the spontaneous haemorrhages from the skin or mucous 
membranes. When, however, they are single, they seem to me of trau- 
matic rather than of pathological origin. 

The most important of the visceral haemorrhages are intracranial. 
These are discussed in the chapter devoted to Birth Paralyses. Rarely 
there may be large haemorrhages into the lung. Here the blood fills the 
air vesicles, the small bronchi, and coagula may be found even in the 
larger bronchi. A large part of a lobe or an entire lobe may be involved. 
On section the condition resembles atelectasis, and it may give the physical 
signs of consolidation. 

The abdominal viscera suffer more than those of the thorax because 
less protected against pressure. Small haemorrhages are not uncommon 
upon the surface of any of the viscera covered by peritoneum. Intra- 
peritoneal haemorrhages are rare, but may be very extensive, amounting to 
9 



98 DISEASES OP THE NEWLY BORN. 

one or two pints. Sometimes no ruptured vessel can be found. The 
haemorrhage may be primarily in the peritoneal cavity, or it may result 
from rupture of one of the viscera, especially the suprarenal capsule. It 
may be large enough to produce death from loss of blood. 

Small surface haemorrhages of the liver are not infrequent. Occa- 
sionally one of considerable size occurs separating the peritoneal covering 
and forming a tumour generally upon the superior surface. Such lacer- 
ation may be produced during labour, and a slow accumulation of blood 
may take place beneath the capsule, death resulting, as in the case re- 
ported by Mendelson (New York), from rupture into the peritoneal cavity 
on the third day. Steffen reports a case of laceration of the capsule of 
the liver in a still-born infant. Of the large haemorrhages, those into the 
suprarenal capsules are perhaps the most frequent. Two cases have re- 
cently occurred in the Sloane Maternity Hospital. In one of these, the 
specimen of which I examined, the capsule was distended nearly to the 
size of an orange, and the kidney surrounded by a mass of blood-clots. 
Blood was extravasated into the retroperitoneal connective tissue, and 
rupture had taken place into the peritoneal cavity, which contained half 
a pint of partly coagulated blood. The child died on the fifth day. This 
case has been reported in full by Tuley.* Ahlfeld has reported a case of 
haemorrhage into both suprarenals. 

Except in the intracranial variety, visceral haemorrhages cause few 
symptoms, and in the great majority of cases the diagnosis is not made. 
Intrapulmonary haemorrhages have given rise to the signs of consolida- 
tion of the lung and even to haemoptysis (MiramV case). The abdominal 
haemorrhages are the most obscure. There may be a general abdominal 
distention with the usual symptoms of loss of blood, or there may be a 
circumscribed swelling. In many cases nothing is noticed until a rupture 
of a subperitoneal haemorrhage takes place into the general peritoneal 
cavity, when there may be sudden collapse and death. 

The visceral haemorrhages are not amenable to treatment. The prog- 
nosis depends upon the size and position of the haemorrhage. In the cases 
of abdominal haemorrhage the diagnosis is extremely obscure and is rarely 
made during life. 

SPONTANEOUS HEMORRHAGES— THE HEMORRHAGIC DISEASE OF 

THE NEWLY BORN. 

A disposition to bleeding is seen with many diseases of the first few days 
of life, especially those of an infectious character, like syphilis and pyaemia. 
With most of these, however, the haemorrhages are small, and the condi- 
tion may be compared to the haemorrhagic tendency seen in certain forms 
of infection of later life, such as measles, smallpox, and malignant endo- 

* Archives of Pediatrics, November, 1892. 



THE HEMORRHAGIC DISEASE. 99 

carditis. There is, however, a class of cases in which the haemorrhages are 
not associated with any other known process, and in which the escape of 
blood from the small blood-vessels is the chief or essential symptom. In 
these cases the bleeding is much more extensive than in the others men- 
tioned. These haemorrhages are characterized by the fact that they are 
spontaneous in origin, having no connection with delivery,, they are mul- 
tiple in location, and, while little influenced by treatment, they tend to 
cease spontaneously after quite a limited time. They are most often from 
the umbilicus, the mucous membranes of the stomach and intestines, or 
beneath the skin, but they may be from almost any mucous surface or 
into any organ of the body. 

Etiology. — Exactly what causes these haemorrhages is as yet unknown, 
but it is something which produces changes in the blood or in the blood- 
vessels, or in both, whereby the vessels are no longer able to hold their 
contents. In this class, as well as in the traumatic haemorrhages, the 
predisposing causes of bleeding in early life must be emphasized — viz., the 
fragile condition of the blood-vessels and the great changes taking place 
soon after birth both in the circulation and in the blood itself. These 
haemorrhages are not common, and are met with much more often in in- 
stitutions than in private practice. In 5,225 births in the Boston Lying-in 
Asylum, Townsend reports 32 cases of haemorrhage, or 0*6 per cent. In 
the Lying-in Asylum of Prague, Ritter observed 190 cases in 13,000 births, 
or 1-4 per cent. In the Foundling Asylum of Prague, Epstein reports 
haemorrhages in 8 per cent of 740 infants. 

These cases, except in very rare instances, are not manifestations of 
haemophilia. Of 576 bleeders collected by Grandidier, only 12 had a his- 
tory of haemorrhage at the time of falling off of the cord, and symptoms 
very rarely appeared before the end of the first year. Haemorrhages in 
the newly-born are more frequent in males, while in haemophilia females 
predominate, 13 to 1. The haemorrhagic disease of the newly-born is self- 
limited, and runs a definite course to recovery or death. The tendency to 
bleed does not extend beyond a few weeks, and often lasts but a few days ; 
those who survive, recover perfectly. Circumcision has been done within 
a few days after the cessation of the haemorrhages without any unusual 
bleeding. In a case lately under observation with the most extensive 
subcutaneous haemorrhages I have ever seen, all tendency to bleed had 
ceased before the separation of the cord, although there had previously 
been bleeding at the navel. A similar case is reported by Townsend. 
These cases are not associated with difficult delivery. In only 6 of Town- 
send's* 50 cases was the labour abnormal. This is borne out by my own 
experience. Many of the children who bleed have previously been anaemic 
and in poor general condition ; but, on the other hand, many have been 

* Archives of Paediatrics, 1894, p. 559. 



100 DISEASES OF THE NEWLY BORN. 

strong and given every indication of being well nourished. Hereditary 
syphilis is associated in a small proportion of the cases — from 2 to 6 per 
cent, according to the observations of Epstein, Eitter, and Townsend. 
In 132 cases of congenital syphilis observed by Mracek, 14 per cent suf- 
fered from haemorrhages. 

A more frequent association with sepsis has been observed. Of the 61 
cases observed by Epstein not less than 29, and of the 190 cases of Bitter,* 24 
were associated with sepsis. In the Sloane Maternity Hospital, New York, 
in 1,500 consecutive births no case of haemorrhage worth mentioning oc- 
curred, and during this period there was not a single case of marked 
sepsis among the infants born in the hospital. During the past year 
(1895) there have been no less than 8 marked cases of haemorrhage in the 
Nursery and Child's Hospital in about 225 deliveries. While it is true 
that more cases of sepsis (pyogenic infection) have occurred among the 
children during this period than is usual, it is striking that not one of 
these haemorrhagic cases gave any evidence of sepsis, and that none of the 
septic cases had bleeding. 

From the foregoing facts it is quite evident that not all the cases of 
bleeding are due to the same cause, and that while this symptom occurs 
in cases of pyogenic infection, the latter does not explain most of the cases 
seen. The circumstances in which the haemorrhagic disease occurs point 
strongly to an infectious origin, but with our present knowledge we cannot 
believe this cause to be the same as in ordinary sepsis — viz., the entrance 
of common pyogenic bacteria. Bacteriological findings thus far have not 
been altogether conclusive. The most important results were obtained 
in two cases studied recently by Gaertner.f In both of these there was 
found in the blood a short bacillus resembling in some respects the bacte- 
rium coli commune, but differing from it in several important points. 
This bacillus, injected into the peritoneal cavity in young animals, chiefly 
dogs a few days old, produced a disease accompanied by haemorrhages re- 
sembling that seen in the newly-born. The bacillus was recovered from 
the blood and all the organs of these animals. In a recent case occurring 
at the Nursery and Child's Hospital, cultures were made eight hours after 
death by Dr. J. J. Mapes. There was found in pure culture in the um- 
bilical arteries, in the heart's blood, and in the spleen, a bacillus which 
in morphological and culture characteristics was apparently identical with 
that described by Gaertner. It will, however, be necessary that many 
other cases shall be recorded before the etiological connection between 
this germ and the disease is established. 

While these haemorrhages are not traumatic, bleeding is exceedingly 
prone to occur in the skin over pressure points such as the back, the 

* (Esterreiches Jahrbnch fur Padiatrik, 1871, 127. 
f Archiv fur Kinderheilkunde, 1895. 



THE HEMORRHAGIC DISEASE. 101 

elbows, the occiput, and the sacrum. It is also common from the mucous 
membranes which are the seat of pathological processes, especially from 
the eyes, the nose, and the genitals. 

Lesions. — In very many of the cases the autopsy shows nothing except 
the haemorrhages in the various situations and the blanching of the organs 
due to the loss of blood. The haemorrhages of the brain are usually me- 
ningeal and diffuse. They are considered more at length in the chapter 
upon Birth Paralyses. The pulmonary haemorrhages are usually small 
and unimportant, amounting only to small extravasations into the sub- 
stance of the lung or ecchymoses of the mucous membrane of the bronchi. 
Ecchymoses may be seen upon the surface of the pleura, the pericardium, 
or the peritoneum, but large haemorrhages into the pleura or pericardium 
are very rare. The thymus gland is often the seat of small extravasa- 
tions. The stomach and intestines may contain considerable blood vari- 
ously disorganized in the different parts of the canal, and there may be 
ecchymoses of the mucous membrane. In addition, ulcers may be found 
in the stomach and duodenum. In twenty-four autopsies upon cases 
with haemorrhage from the stomach and intestines collected by Dusser,* 
ulcers were found in the stomach in nine cases, and in the intestines in 
four. These ulcers are multiple and are small, resembling the follicular 
ulcers of the colon. They are usually superficial, but may extend to the 
muscular coat and may even perforate. I have myself found ulcers in the 
stomach in a single case. They were associated with a moderate amount 
of follicular gastritis. The intestinal ulcers are found only in the duode- 
num and resemble those of the stomach. The cause of these ulcers is 
somewhat obscure ; some of them are undoubtedly dependent upon in- 
flammatory changes probably of infectious origin ; others have been com- 
pared to the peptic ulcers of later life, and are attributed to thrombi in the 
blood-vessels of the mucous membrane. These ulcers are found in but a 
small proportion of the cases in which bleeding occurs from the alimen- 
tary tract, and they may be wanting even where it has been very profuse. 

Small extravasations may be seen upon the surface of the liver, the 
spleen, or the kidneys. They may also be found in the substance of these 
organs. The large haemorrhages upon the surface of the liver, into the 
suprarenal capsules and other subperitoneal extravasations have been in- 
cluded, improperly perhaps, in the group of traumatic haemorrhages dis- 
cussed in the preceding chapter. From a rupture of any of these there 
may be large extravasations into the peritoneal cavity. Microscopical ex- 
aminations of the blood-vessels have been made in but a small number of 
cases. Mracek claims to have found evidences of endarteritis in some of 
the syphilitic cases in which there was bleeding. The changes found 
in the blood have not been uniform and have as yet been only im- 



* These, Paris, 1889. 



102 DISEASES OF THE NEWLY BORN. 

perfectly studied. The associated lesions found are most frequently those 
due to sepsis. 

Symptoms. — The time of beginning is most frequently in the first 
week of life, rarely after the twelfth day, although it has been observed as 
late as the sixth week. As a rule, the haemorrhages from the stomach 
and intestines begin earlier than those from the navel or the skin. The 
location of the haemorrhage in Bitter's 190 cases was as follows : Um- 
bilicus, 138 (umbilicus alone, 97) ; intestines, 39 ; mouth, 28 ; stomach, 
20 ; conjunctivae, 20 ; ears, 9. In Townsend's 50 cases : Intestines, 20 ; 
stomach, 14 ; mouth, 14 ; nose, 12 ; umbilicus, 18 (umbilicus alone, 3) ; 
subcutaneous ecchymoses, 21 ; abrasion of skin, 1 ; meninges, 4 ; cephal- 
haematoma, 3 ; abdomen, 2 ; pleura, lungs, and thymus, 1 each. 

In many cases nothing is noticed until the haemorrhage begins. The 
child may be previously healthy or feeble. The first bleeding noticed may 
be from the stomach, intestines, or any of the mucous surfaces, beneath 
the skin, or from the umbilicus. The amount of blood lost in most cases 
is not great, but there is a continuous oozing. The total haemorrhage 
may be only one or two drachms or it may reach several ounces. The 
skin is usually pale, the pulse feeble, and the general condition one of con- 
siderable prostration, often from the outset. In all cases there is rapid 
loss of weight. The temperature may be high, low, or subnormal. A 
marked elevation of temperature may depend not upon the haemorrhage 
but upon associated conditions. Fluctuations in temperature during the 
first three days are so common from disturbances of nutrition, that I attach 
much less importance than have some writers to this symptom. Icterus is 
not more frequent than among other infants. In a large number of the 
cases there is diarrhoea. Convulsions often occur at the close of the disease. 

The duration of the disease in cases which recover is usually but one 
or two days. In fatal cases it is rarely more than three days, and often 
less than one. Death more frequently results from the gradual failure of 
all the vital forces than from a rapid loss of blood. 

Umbilical hc&morrhage. — A slight oozing from the umbilicus not in- 
frequently occurs when the ligature has been improperly applied, or when 
there is so much shrinking of the cord that the ligature has loosened. 
Sometimes rough handling at the time of the separation of the cord may 
excite a little bleeding. All the above conditions, however, are usually of 
trivial importance and are readily controlled by simple measures. Spon- 
taneous haemorrhage is quite a different matter. It is rather later than 
bleeding from the mucous membranes, usually occurring between the 
fourth and the seventh day. There may be bleeding into the cord as well 
as from its free extremity before it separates ; after separation from the 
stump. A slight stain upon the dressing is usually the first note of warn- 
ing, but in exceptional circumstances a gush of blood is the first symptom. 
The haemorrhage may be temporarily arrested by various means, but it 



THE HEMORRHAGIC DISEASE. 103 

shows a strong tendency to recur in spite of everything which is done. 
The general symptoms depend upon the amount of bleeding and the rap- 
idity with which it occurs. It is the same as in other haemorrhages of the 
newly-born. The usual duration is two or three days. It has been known, 
however, to persist for twelve or fourteen days, and it may be fatal in less 
than twenty-four hours from the time it is noticed. 

Haemorrhage from the stomach and intestines. — This occurs much 
less frequently from the stomach than from the intestines. The latter 
is called melaena. Gastro-enteric haemorrhages begin, in the great ma- 
jority of cases, during the first three days of life. Of Dusser's 75 cases, the 
haemorrhage began on the first day in 24 cases ; on the second day in 22 
cases ; on the third day in 9 cases ; in only 10 cases later than the ninth 
day, and in no instance later than the twelfth day. The appearance of 
the blood vomited depends upon the length of time it has remained in 
the stomach. Usually it is in dark brown masses, and not very abun- 
dant; more rarely bright red blood may be ejected. The quantity varies 
from one drachm to half an ounce. Vomiting is liable to be excited by 
nursing. The blood discharged from the bowels is always dark coloured, 
usually intimately mixed with the stool, very rarely in clots. If in doubt 
between blood and meconium, one should look for the corpuscles with the 
microscope. When this is not conclusive on account of the disorganiza- 
tion of the corpuscles, a chemical test for haemoglobin should be made. 
Concealed haemorrhage into the stomach may take place, which may even 
be sufficient to produce death, no blood being vomited or passed by the 
bowels. In such cases the autopsy may reveal quite a large quantity of 
blood, both in the stomach and intestines. 

Hemorrhage from the mouth. — The quantity of blood is rarely large; 
but it is here that it is often first seen. Its source may be the mucous 
membrane of the mouth, pharynx, oesophagus, stomach, or bronchi. It 
may be associated with ulceration of the hard palate, with thrush, or with 
fissures of the lips. 

Haemorrhages from the nose are infrequent, and are more often due to 
syphilis than to other causes. These are rarely profuse, but are frequently 
repeated. 

Subcutaneous haemorrhages. — These may appear in places exposed to 
pressure, such as the sacrum, heels, occiput, or back ; or in others which 
are not so exposed, as the abdomen, axillae, or thighs. They may follow 
other lesions of the skin, such as pemphigus, eczema, or furunculosis. In 
some cases these haemorrhages are very extensive, as in one recently 
under observation, where nearly one third of the thorax was covered. 
The extravasations are surrounded by an indurated border. Where they 
occur alone or form the principal lesion, the prognosis is favourable. 

Hamiaturia. — The urine is not only stained with blood, but sometimes 
contains clots. This haemorrhage may have its origin in the bladder, ure- 



104 DISEASES OF THE NEWLY BORN. 

thra, or kidney. Blood coming from the kidney is sometimes due to the 
irritation of uric-acid infarctions, and may have nothing to do with the 
general haemorrhagic disease. 

Hemorrhage from the conjunctiva. — The blood usually comes in drops 
from between the eyelids, chiefly from the tarsal surface. It is generally 
preceded by conjunctivitis. 

Hemorrhage from the ears may originate in the external meatus or 
the middle ear. It is generally preceded by otitis. 

Hemorrhage from the female genitals. — This not infrequently occurs 
without haemorrhages elsewhere, and under such circumstances is rarely 
serious. Cullingsworth has collected thirty-two cases in children under 
six weeks of age — no case having resulted fatally. These are not to be re- 
garded as cases of precocious menstruation. They are frequently preceded 
by catarrhal inflammations of the vagina. 

Diagnosis. — This is generally easy, as the haemorrhages are usually 
multiple and some of them external. A slight haemorrhage from the 
intestine may be easily overlooked. Large haemorrhages into the internal 
organs also are obscure and not often recognised. Spurious haemorrhages 
from the stomach may occur as in the vomiting of blood which has been 
swallowed during parturition or sucked from the breasts. Bleeding may 
take place from the mouth, nose, or pharynx, and, after being swallowed, 
the blood may be vomited. When the principal bleeding is from the nasal 
mucous membrane, syphilis should be suspected. 

Prognosis. — In all circumstances the haemorrhage disease in the 
newly-born has a bad prognosis. Of seven hundred and nine cases col- 
lected by Townsend, the mortality was seventy-nine per cent. No ob- 
seryer has seen more than one third of his cases recover. In any single 
case the prognosis depends upon the extent and severity of the haemor- 
rhage, upon the vigour of the child, and upon how well it can be nour- 
ished. No case should be looked upon as hopeless, for perfect recovery has 
repeatedly taken place where it seemed impossible. 

Treatment. — The administration of drugs internally for the control of 
haemorrhage is, in my opinion, entirely without influence upon the. dis- 
ease. The general treatment should have reference to maintaining the 
nutrition by careful feeding, judicious stimulation, and attention to the 
circulation, the body temperature, and the general condition of the child. 
External haemorrhages may be treated locally. Bleeding points on the 
skin or mucous membranes within reach, are best treated by the applica- 
tion of chromic acid fused on a probe, or of nitrate of silver. Umbilical 
haemorrhage, when resisting this treatment, is sometimes arrested by 
digital pressure, which must often be continued for one or two days. 
Bleeding from large vessels, when not thus controlled, requires that the 
umbilicus should be ligated en masse after being transfixed by a hare-lip 
pin. In such cases, however, secondary haemorrhage often occurs at the 



BIRTH PARALYSES. 105 

separation of the slough, so that the procedure is frequently unsuccessful. 
The actual cautery is open to the same objection. There are a few in- 
stances on record where bleeding has been controlled by covering the 
wound with plaster-of-Paris. Astringents are applicable to all cases of 
external haemorrhage — from the nose, skin, vagina, and the eyes. Astrin- 
gent injections for gastro-enteric haemorrhages are practically useless, as 
the blood is almost invariably either from the stomach or from the upper 
part of the small intestine. 



CHAPTER VI. 
BIRTH PARALYSES. 

Bieth paralyses are chiefly due either to pressure upon the child by 
the parts of the mother or to artificial means employed in delivery. They 
may be cerebral, spinal, or peripheral. 

Cerebral paralyses are in almost every instance due to meningeal haem- 
orrhage. Very infrequently they depend upon cerebral haemorrhage, 
laceration of the brain, or pressure from a depressed fracture. 

Spinal paralyses are extremely rare, and only a few examples are on 
record. They are due to laceration of, or haemorrhage into the cord or its 
membranes. These lesions produce paraplegia, the exact distribution of 
which depends upon the point at which the cord is injured. 

Peripheral paralyses usually affect the face or the upper extremity. 
Paralysis of the face is due in most cases to the application of the 
forceps. Paralysis of the upper extremity is most frequently of the 
"upper-arm type," and is known as Erb's paralysis. It usually follows 
extraction in breech presentations. Peripheral paralysis of the lower 
extremity is almost unknown. 

CEREBRAL PARALYSIS. 

Cerebral paralysis is often used synonymously with meningeal haemor- 
rhage. This lesion is not infrequent, and is of great importance not only 
from its immediate effects, but because upon it depend many of the cere- 
bral paralyses seen in later life. According to Cruveilhier, at least one 
third of the deaths of infants which occur during parturition are due to 
this cause. 

Etiology. — The same predisposing causes exist in the cases of menin- 
geal haemorrhages as in others occurring at this time. A small number of 
cases are associated with syphilis ; others with pyogenic infection. In a 
few cases there is a history of an injury— usually a fall or blow upon the 
abdomen— during the last months of pregnancy. Meningeal haemorrhage 
10 



106 DISEASES OP THE NEWLY BORN. 

may occur as one of the lesions in the hemorrhagic disease of the newly- 
born. The most important causes, however, are connected with parturi- 
tion. These hemorrhages are essentially mechanical, and are favoured 
by everything which increases or prolongs pressure upon the head. The 
conditions with which they are associated are tedious labour, breech pres- 
entations with difficulty in extracting the head, instrumental deliveries, 
and premature births. The majority occur in first-born children. Certain 
cases are associated with cardiac malformations — according to Bednar, a 
small aorta with hypertrophied heart, or the transposition of the large 
blood-vessels. In many of the cases there is also a haemorrhage outside 
the skull. 

Lesions. — These haemorrhages are very much more common at the 
base than at the convexity, and at the posterior, than at the anterior part 
of the skull. They are most frequently found over the cerebellum and 
the occipital lobes of the cerebrum. The entire extravasation is often 
beneath the tentorium. The extent of the haemorrhage is exceedingly 
variable. There may be a single large clot at the convexity or at the base 
(Plate II), the haemorrhage may be limited to the convexity of one 
hemisphere, or it may cover nearly the entire surface of the brain. Dif- 
fuse haemorrhages are more common than a single circumscribed clot. 
Of eleven recent cases collected by McNutt (New York), in seven cases 
with vertex presentations the lesion was principally at the base, and usu- 
ally limited to that region. In four breech cases, however, it was prin- 
cipally at" the convexity. The source of the blood may be a laceration of 
one of the sinuses of the dura mater caused by the overlapping of the 
parietal bones. This was found in one of the cases of Hirst (Phila- 
delphia). Much more frequently the blood comes from one of the cere- 
bral veins, or from the capillary vessels of the pia mater. In thirty- 
seven of Bednar's fifty- two cases, the extravasation was beneath the pia 
mater. In the remainder it was between the pia mater and the dura — 
i. e., in the arachnoid cavity. Haemorrhages between the dura and the 
skull may be said never to occur except when associated with fracture. 
If the child is still-born, or if death has occurred on the first or second 
day, the blood is partly fluid and partly coagulated ; later it is entirely 
coagulated and may have undergone partial absorption. The amount of 
extravasated blood varies between one drachm and four ounces, the aver- 
age amount being about one ounce. The blood extends into the fissures 
between the convolutions and sometimes into the ventricles along the 
choroid plexus, although this is rare. In large haemorrhages the brain 
substance is softened and in places may be quite disintegrated ; but with 
small extravasations these changes are very slight. In cases which survive 
for two or three weeks there is usually a certain amount of meningitis. 
The later changes — those of arrested development of the cortex aud cere- 
bral sclerosis — will be considered in the chapter devoted to Cerebral Pa- 



PLATE II. 




Meningeal ELemorrhage in the N"ewly-Born. 

From a patient in the Nursery and Child's Hospital, dying on the sixtli day. 
Primary respirations poor; child very dull and apathetic, refused to nurse; once vom- 
ited blood and had an ecchymosis of the right conjunctiva. On the last day, high 
temperature (105 P.) and general convulsions. Some changed blood found in the 
stomach and intestines at the autopsy; brain greatly congested, and at the base was 
the clot shown in the picture. 



CEREBRAL PARALYSIS. 107 

ralyses in the section on Diseases of the Nervous System. Haemorrhages 
into the membranes of the upper part of the cord are found in a large 
proportion of the fatal cases. Associated haemorrhages of the lungs and 
other organs are not uncommon. 

Symptoms. — If the haemorrhage is large, the child is usually still-born, 
although its movements may have been active up to the commencement of 
labour. When the haemorrhage is not so large as to be immediately fatal, 
the child may show no symptoms except dulness or torpor, with feeble 
or irregular respiration, death following within the first twenty-four hours. 
A large proportion of the cases are born asphyxiated, and frequently 
they are resuscitated only after considerable effort. They nurse feebly, 
often with great difficulty. Convulsions are common in cases which last 
for four or five days, and more with cortical haemorrhages than with those 
at the base. Opisthotonus is sometimes present, and may be very marked. 
The limbs may be rigidly extended, and the hands clenched. More rarely 
there is complete relaxation of all the muscles. Sometimes there are auto- 
matic movements. The respiration is usually disturbed ; in most cases it 
is slow and irregular. The pulse is feeble and slow. The pupils are more 
frequently contracted than dilated, and there may be oscillation of the 
eyeballs. In large haemorrhages there is marked bulging of the fontanel, 
and often separation of the sutures. If the haemorrhage covers one hemi- 
sphere, there is hemiplegia of the opposite side. Small localized cortical 
haemorrhages may cause paralysis of the face, arm, or leg, according to 
the position of the lesion, or localized convulsions. In large haemorrhages 
at the base convulsions are rare, and death occurs early, usually in the first 
two days. In extensive cortical haemorrhages convulsions and rigidity of 
the extremities are frequent, and life is prolonged indefinitely. 

The majority of the fatal cases die within the first four days. In those 
lasting a longer time the symptoms are tonic spasm of the trunk, or of one 
or more of the extremities, localized paralysis — monoplegia, diplegia, or 
hemiplegia, according to the lesion — with localized or general convulsions 
often continuing for two or three weeks and gradually subsiding. There 
is frequently a slight rise in temperature due to secondary inflammation. 
The mildest cases may show no symptoms at birth, and nothing abnormal 
may be noticed until the child is old enough to walk or talk. In those 
more severe there may be gradual and continuous improvement of the 
early symptoms, and the case may go on to complete recovery, but more 
frequently there results some permanent damage to the brain. The fol- 
lowing observation of McNutt illustrates the course and termination of 
one of the severe cases of meningeal haemorrhage : 

Breech presentation, tedious labour, head delivered by forceps, almost 
continuous convulsions for the first nine days. After the convulsions 
there was complete paralysis of both sides of the body, not involving the 
face. The child never walked or spoke ; the physical development was 



108 DISEASES OF THE NEWLY BORN. 

very backward ; the limbs became contractured ; death occurred at two 
and a half years, from pneumonia. The autopsy showed atrophy of the 
brain on both sides about the fissure of Eolando. 

The main diagnostic symptoms in recent cases are stupor, rigidity, 
convulsions, paralysis, and opisthotonus. These vary with the extent and 
situation of the lesion. The minor symptoms are changes in the pupils, 
oscillation of the eyes, and bulging of the fontanels. 

Prognosis. — Large haemorrhages at the base are usually fatal. Quite an 
extensive haemorrhage over the convexity is compatible with life. The 
case may recover, as far as the immediate symptoms are concerned, but 
with serious damage to the brain. Smaller haemorrhages over the con- 
vexity may be followed by complete recovery, but in the majority of cases 
more or less injury to the brain results, the full extent of which may not 
be seen for many years. 

Treatment. — This is mainly prophylactic, the chief indication being to 
shorten tedious labours by the early use of the forceps. In a large num- 
ber of cases where the haemorrhage has been attributed to the forceps, the 
damage has rather been the result of the long-continued pressure before 
they were used. Nothing can be done after delivery to limit the amount 
of the haemorrhage, except to keep the child as quiet as possible and to 
relieve individual symptoms as they arise. 

FACIAL PARALYSIS. 

The usual cause of facial paralysis is the use of the forceps, but this 
does not explain all the cases. The etiology of those in which the forceps 
have not been used is still somewhat obscure. In peripheral facial palsy 
the nerve is pressed upon either near its exit from the stylo-mastoid fora- 
men, or where it crosses the ramus of the jaw, at which point the parotid 
gland gives it but little protection in the newly-born. If the lesion is in 
front of this point, any one of the terminal branches may be affected ; 
most frequently it is the temporo-facial branch. As only one blade of the 
forceps commonly touches the face in this region, the paralysis is, as a 
rule, unilateral. 

Eoulland has reported several cases not due to the forceps. In these 
the pressure is believed to have been produced by the promontory of the 
sacrum at the superior strait, or by the ischium at the inferior strait, as 
paralysis followed when the head was long arrested at one of these points. 
It was not seen with face or breech presentations. When facial paralysis 
is of central origin it depends generally upon a meningeal haemorrhage, 
and the arm and leg of the same side as the face are involved. It is, how- 
ever, possible for a very small cortical haemorrhage to produce paralysis of 
the face only. This occurred in a case reported by McNutt. 

In repose, the only symptom noticed may be that the eye remains open 
upon the affected side, owing to paralysis of the orbicularis palpebrarum. 



PARALYSIS OF THE UPPER EXTREMITY. 109 

When the muscles are called into action, as in crying, the whole side of 
the face is seen to be affected. The paralyzed side is smooth, full, and 
often appears to be somewhat swollen. The mouth is drawn to the side 
not affected. In this paralysis, the tongue, of course, is not implicated. It 
is therefore rare that nursing is seriously interfered with.* If the pa- 
ralysis is of central origin, only the lower half of the face is involved, 
while in peripheral paralysis, as the trunk of the nerve is injured, the 
upper half of the face, including the orbicularis palpebrarum, is also 
affected. 

The paralysis is generally noticed on the first or second day of life, 
and does not increase in severity. Its course and termination depend 
upon the extent of the injury done to the nerve. Some idea of this may 
often be gained by the amount of injury to the soft parts, although this 
is not an infallible guide. In cases not due to the forceps, the paralysis is 
slight and disappears in a few days; the great majority of the forceps 
cases follow the same favourable course, the paralysis gradually disappear- 
ing without treatment in about two weeks. In more serious cases it may 
last for months, or it may even be permanent. The reaction of degenera- 
tion is present in these severe cases, and there may even be perceptible 
atrophy of the muscles. This symptom is fortunately extremely rare. 

Treatment. — Nothing should be done for the first ten days except to 
protect the eye and keep it clean. If improvement has begun by the end 
of this time, the probabilities are that the case will require no treatment. 
If no improvement has taken place by the end of the. third or fourth week, 
electricity should be used regularly and systematically. If the muscles 
respond to it, the faradic current may be employed ; if not, galvanism 
should be used. The electrical treatment should be continued for several 
months, or until recovery has taken place. 

PARALYSIS OF THE UPPER EXTREMITY. 

When this is due to a peripheral lesion it probably never involves the 
entire arm, but affects only certain muscles or groups of muscles. Al- 
though commonly occurring after an artificial delivery, it may be seen in 
cases where the labour has terminated naturally. Roulland f has reported 
a case in which deltoid paralysis, occurring in a large child, was attributed 
to pressure upon the shoulder during labour. In vertex presentations, 
paralysis is most frequently due to the forceps where one of the blades 
has extended down upon the neck, injuring the lower cervical nerves. It 
may be produced by traction with the finger in the axilla. Roulland 
reports a unique case of paralysis of both extremities, apparently due to 

* In this connection it is to be remembered that the principal part in nursing is 
done by the tongue, and not by the Lips. 
f Paralysies des nouveau-nes, Paris, 1887. 



110 



DISEASES OF THE NEWLY BORN. 



c 



1 






the cord being very tightly wound around the neck. The great propor- 
tion of all cases of paralysis of the upper extremity follow extraction in 
breech presentations. The injury is usually inflicted by traction upon the 
shoulder in the delivery of the head, or in bringing down the arms when 
they are above the head. In the latter case the paralysis may be double 
and associated with fracture of the clavicle or humerus. In shoulder 
presentations, paralysis may be produced by traction upon the arm itself. 

The most common form of peripheral paralysis is that known as the 
" upper-arm type," or Erb's paralysis, in which the injury is inflicted at 
the anterior border of the trapezius muscle at the lower part of the neck, 

usually in such a position 
as to affect the fifth and 
sixth cervical nerves. The 
muscles paralyzed are the 
deltoid, biceps, brachialis an- 
ticus, supinator longus, and 
sometimes the supra- and in- 
fra-spinatus. All these mus- 
cles may be involved, or only 
part of them, and in varying 
degrees. In case the injury 
is slight, the paralysis may 
not be noticed for some 
weeks. If severe, it is evi- 
dent in the first few days. 
The arm hangs lifeless by 
the side ; it is rotated in- 
ward, the forearm pronated, 
the palm looking outward 
(Fig. 19). The forearm and 
hand are not affected. In 
severe cases there may be 
anaesthesia of the outer surface of the arm, in the region supplied by 
the circumflex and external cutaneous nerves. This is rarely marked, 
and in its slighter degrees it is very difficult to determine. It is char- 
acteristic of this paralysis that the triceps is not affected, so that power 
to extend the forearm remains, although it cannot be flexed. Atrophy 
of the paralyzed muscles occurs after a few weeks, but the muscles are 
so small and so covered with fat that it is rarely noticeable before 
the second year. It is most conspicuous in the deltoid. In all severe 
cases the reaction of degeneration is present. In some of the cases of 
long standing there occurs a shortening of the tendon of the subscapu- 
laris muscle, often associated with subluxation of the humerus. The 
paralysis may be complicated with fracture of the clavicle, the neck of 




Fig. 19. — Erb's paralysis, infant two months old. 



TUMOURS OF THE UMBILICUS, MASTITIS, ETC. m 

the scapula, or the shaft of the humerus, or with epiplryseal separation of 
its head. 

The prognosis depends upon the severity of the injury and also upon 
the time when treatment is begun. The great majority of cases recover 
spontaneously in two or three months, improvement being observed within 
a few weeks, first in the biceps and last in the deltoid. Spontaneous re- 
covery is not to be looked for unless it occurs within the first three 
months. Xot infrequently some degree of paralysis persists until the 
third or fourth year, and in some of the muscles, usually the deltoid, it 
may even be permanent. If the muscles respond to faradism, rapid im- 
provement can generally be prophesied. If the reaction of degeneration 
is present, improvement will be slow and the paralysis may be permanent. 

The diagnosis is usually not difficult, since the great majority of cases 
are of the " upper-arm type " with classical symptoms. Peripheral palsy 
of the arm can scarcely be confounded with that of cerebral origin. If 
the lesion is central it is one of the rarest occurrences for the arm alone to 
be involved ; either the leg or face, or both, are generally likewise affected. 
If the case does not come under observation until the child is a year old, 
it may be difficult, or without a good history, it may be impossible to dis- 
tinguish peripheral paralysis from that due to polio-myelitis. The peculiar 
group of muscles involved in Erb's paralysis is the only diagnostic point. 

In recent cases the disability resulting from the tenderness or pain of 
syphilitic epiphysitis may simulate paralysis, but there is lacking the 
characteristic position of the arm, and a careful examination discloses the 
fact that the paralysis is only apparent. This may affect both sides. 
Fracture of the clavicle or epiphyseal separation of the head of the hu- 
merus may also be mistaken for paralysis. In cases of long standing, 
paralysis of the deltoid may resemble dislocation of the humerus. The 
reaction of degeneration differentiates paralysis from surgical injuries 
with similar deformities. 

The treatment consists in the use of electricity, which should be begun 
at the end of the first month at the latest, and used regularly. If the mus- 
cles respond to faradism this may be employed, but in most severe cases 
they do not, and galvanism must be used, according to the rules laid down 
for facial paralysis. 



CHAPTER VII. 

TUMOURS OF THE UMBILICUS, MASTITIS, ETC. 

Granuloma. — This is nothing more than a mass of exuberant granula- 
tions at the umbilical stump. The mass is generally about the size of a 
pea — sometimes larger — bleeds readily, and has a thin, purulent discharge. 



112 



DISEASES OF THE NEWLY BORN. 



It is promptly cured by the application of any simple astringent ; pow- 
dered alum is probably the best. In case this is not successful, the granu- 
lations may be touched with nitrate of silver or snipped off with scissors. 

Adenoma, Mucous Polypus, or Diverticulum Tumour — Umbilical Fis- 
tula. — The first three terms are used synonymously to describe an um- 
bilical tumour covered with a mucous membrane which is similar in 
structure to that of the small intestine. It is usually associated with an 
umbilical fistula. This tumour is formed by a prolapse at the navel of the 
mucous membrane of Meckel's diverticulum. This diverticulum is the 
remains of the omphalo-mesenteric duct. When it is present in infants, 
it is found in various stages of development. Most frequently there is a 




ABC D 

Fig. 20. — Umbilical fistula and tumours produced by prolapse of Meckel's diverticulum (Barth.) 

blind pouch a few inches long given off from the lower part of the ileum. 
In other cases it may remain patent quite to the umbilicus, causing a 
faecal fistula (Fig. 20, A). As the intestine below it is generally normal, 
this fistula may persist for months or even years, giving rise to no symp- 
toms except a slight faecal discharge from the umbilicus. In certain cases 
intestinal worms have been discharged through it. It may close sponta- 
neously or be closed by operation. 

A prolapse of the mucous membrane lining the diverticulum produces 
an umbilical tumour with a fistula at its summit (Fig. 20, B). This is the 
most common form. A cross-section shows under the microscope the 
structure of the intestinal mucous membrane both as an external covering 
and lining of the fistulous tract. The prolapse may involve not only the 
mucous membrane but the entire intestinal wall. There then exists a 
conical tumour with a fistula which has but one external opening, but at 
a short distance from the surface it bifurcates, one branch leading upward 
and one downward (Fig. 20, 0). A continuation of the prolapse gives a 
broad pedunculated tumour (Fig. 20, D), which may reach the size of a 
man's fist. Its covering is the same as in the other forms. It may con- 
tain several coils of intestine. In this form there are usually two fistulous 
openings (a, b) which communicate with the intestine. 

In all of these cases the tumour is smooth, irreducible, of a rosy pink 



UMBILICAL HERNIA. 113 

colour, and from its surface there oozes a mucous discharge. Microscop- 
ical examination shows the external covering to be the same in structure 
as the intestinal mucous membrane. These tumours are generally small, 
varying in size from a pea to a small cherry, but they may be very much 
larger. A faecal fistula usually, but not invariably, coexists.* In the con- 
dition represented in Fig. 20, B, it is easy to see how an obliteration of the 
fistula may occur. The small tumours are readily cured by the ligature. 
The larger ones are usually associated with other serious malformations 
of the intestines, which make the outlook bad in almost every instance. 

UMBILICAL HERNIA. 

This is exceedingly common, and while not often serious it is a source 
of great annoyance. Umbilical hernia is much more common in female 
children than in males, and more frequent in those who are thin and 
poorly nourished than in plump, healthy infants. In the majority of in- 
stances the tumour is from one fourth to one half an inch in diameter ; it 
may, however, be very large, and may even become strangulated. Cases 
of congenital umbilical hernia sometimes require surgical operation be- 
cause of strangulation. The ordinary cases require only mechanical treat- 
ment. The most important thing is prevention. For this purpose it is 
necessary, after the cord has separated, to place a firm pad over the navel, 
and to use a snug abdominal band for the first two or three months. After 
this period it is uncommon for hernia to develop. In cases coming un- 
der observation after the third or fourth month, the pad and abdominal 
bandage are inadequate, and other means must be employed to retain the 
hernia. The best of these consists in the use of two adhesive strips 
applied obliquely over the abdomen, crossing at the umbilicus, the skin 
along the median line being folded inward so as to overlap the tumour, 
this forming the retention pad. Another method often successful is 
the use of a common wooden button or a piece of lead covered with kid 
and held in position either by rubber plaster or an abdominal band. 
These must be worn constantly for several months at least. The treat- 
ment of these cases after the first year, is extremely unsatisfactory. There 
is no truss or other apparatus for retention which I have ever seen which 
was wholly satisfactory. In a small hernia where the tumour is less than 
half an inch in diameter it is really unnecessary to use any form of appa- 
ratus, since these cases ordinarily show little or no tendency to increase in 
size, and the retention apparatus causes more annoyance than the hernia. 
These small hernias seem to disappear spontaneously during childhood, as 
they certainly are not often seen in children over seven years of age. 



* For report of such a case, and a fuller description, see article by the author, New 
York Medical Record, April 21, 1888. 

11 



114 DISEASES OF THE NEWLY BORN. 



MASTITIS. 



According to Guillot, a certain amount of secretion in the breasts of 
the newly-born is physiological. It is certainly very common. It is most 
abundant between the eighth and fifteenth days, but may continue in 
small quantities as late as the third month. It is seen with equal fre- 
quency in both sexes. The quantity of the secretion amounts in most 
cases only to a few drops ; in some, however, as much as a drachm has 
been obtained. Chemical analysis has shown this secretion to be essen- 
tially the same as the adult milk — containing fat, sugar, proteids, and 
salts. In gross appearance it resembles colostrum. The researches of 
Sinety * have shown that the mammary gland of the newly-born contains 
cul-de-sacs lined with secreting cells, resembling those of the adult. Dur- 
ing the period of secretion the gland is slightly reddened, its vessels turgid, 
and all the signs of functional activity are present. This condition in it- 
self is of no practical importance, and in most cases, if left alone, the 
secretion ceases spontaneously after a week or ten days. If abundant, it 
can usually be dried up by painting the gland with tincture of belladonna. 
It sometimes happens, however, that the presence of this secretion tempts 
the nurse or attendant to rub or squeeze the breast. Such manipulation 
occasionally leads to serious results by exciting a mastitis which may ter- 
minate in abscess. Mastitis is not a very rare condition, and although 
the inflammation is not usually severe, it may be serious and even fatal. 
The predisposing cause is the congestion which accompanies functional 
activity, usually in the second week. The exciting cause is most often 
some form of traumatism — undue pressure, the squeezing of the breasts, 
or rough handling by the nurse. Through abrasions or fissures thus pro- 
duced, micro-organisms find a ready entrance with the same result as in 
the adult. It seems possible that the germs may enter through the lactif- 
erous ducts without any abrasion of the skin. Want of cleanliness is al- 
ways a favourable condition for such infection. 

The symptoms of mastitis usually begin during the second week of 
life. There are redness, swelling, and the usual signs of inflammation, 
which may terminate in resolution or in suppuration. The process may 
be limited to the mammary region, or a diffuse phlegmonous inflammation 
may be set up, as in a case reported by Bush,f in which there was ex- 
tensive sloughing of the tissues of the whole of one side of the chest, with 
a fatal result. In the great majority of cases the process does not reach 
this degree of intensity, but suppuration with the formation of single or 
multiple abscesses is not uncommon. In the female it is possible for the 
cicatrization which follows such an inflammation to interfere with the sub- 



* Gazette Medicale, No. 17, 1885. 

f New York Medical Journal, March, 1881. 



INTESTINAL OBSTRUCTION. 115 

sequent development of the gland. The general symptoms are restlessness, 
loss of sleep, disinclination to nurse, and loss of weight. In cases of diffuse 
phlegmonous inflammation the general symptoms are those of pyogenic 
infection. Jourda * has collected fifteen cases of mammary abscess, twelve 
of which recovered. They began between the fourth and the forty- second 
days. In eleven cases, only one side was involved ; in four, both sides. 

Mastitis is usually due to want of cleanliness or to meddlesome inter- 
ference ; the parts should therefore be kept scrupulously clean, and on no 
account should squeezing of the breasts be permitted. They should be pro- 
tected by a simple cotton pad. If acute inflammation develops, it should be 
treated in the beginning by hot applications. Should pus form, early in- 
cision with free drainage and general tonic and stimulant treatment are 

indicated. 

INTESTINAL OBSTRUCTION. 

The most frequent causes of intestinal obstruction in the newly-born 
are malformations of the intestine ; rarely it may be due to pressure from 
tumours, or from a persistent omphalo-mesenteric duct or artery. The vari- 
ous pathological conditions present in intestinal malformations are consid- 
ered in the chapter on Diseases of the Intestines. The most common seat 
of obstruction is at the anus, the bowel being normally formed through- 
out, lacking only the external orifice. The next most frequent condition 
is obstruction in the rectum, which may be due either to a membranous 
septum in the gut, or to obliteration of the tube for some distance. 
These rectal obstructions are readily recognised. By the examining finger 
or a bougie the lower limit of the obstruction can be made out, but there 
is no means by which the upper limit can be determined except by open- 
ing the abdomen. When the obstruction is above the rectum, localization 
is more difficult; but the most frequent seat is the duodenum. Of 38 
cases collected by Gaertner, the seat of obstruction was the duodenum in 
19 cases, the jejunum in 3, the ileum in 11, the colon in 6, the ileum and 
colon in 1. There is often obstruction at more than one point. 

The symptoms vary with the seat and the degree of the obstruction. 
In atresia of the anus or rectum there is at first simply an absence of all 
discharges from the bowel. Later there is abdominal distention from 
dilatation of the sigmoid flexure and colon. After several days vomiting 
begins. If there is atresia of the duodenum or any part of the small 
intestine, vomiting begins early — usually by the second day of life — and it 
is persistent. Nothing is passed from the bowels after the first dark dis- 
charge of the contents of the colon, which is chiefly mucus. There is 
rapid asthenia, and death from inanition usually occurs in four or five days. 
The higher the obstruction the shorter the duration of life. If the con- 
dition is one of stenosis only, the symptoms are similar to those described 

* These, Paris, 1889. 



lie DISEASES OF THE NEWLY BORN. 

but less severe, and life may be prolonged for several weeks, or even 
months. The constipation in these cases is not absolute. When the 
cause of obstruction is external pressure, the symptoms do not always be- 
gin immediately after birth. I have recently seen a child in whom noth- 
ing abnormal was noticed for the first three weeks, but at the end of that 
time there developed all the signs of acute intestinal obstruction. Lapa- 
rotomy revealed a loop of intestine constricted by a tiny cord, which was 
probably the remains of the omphalo-mesenteric duct. 

Cases of imperforate anus and membranous septum in the rectum are 
readily relieved by proper surgical treatment. In the other varieties of 
obstruction, whether in the rectum, in the colon, or in the small intestine, 
although life may be prolonged by the formation of an artificial anus, the 
ultimate result is almost invariably fatal, death usually resulting from 
marasmus during the early weeks of life. 

DIAPHRAGMATIC HERNIA. 

This is due to a congenital deficiency in the diaphragm, which in nearly 
all the reported cases has occurred on the left side at its anterior portion. 
The opening may be so small as to allow the passage of only a single coil 
of intestine, or so large that a considerable part of the abdominal contents 
find their way into the thoracic cavity. This causes displacement of the 
heart to the right, prevents the expansion of the left lung, and if it occur 
in intra-uterine life may prevent the development of the lung. In Gau- 
tier's case the left half of the diaphragm was deficient, and nearly all of 
the small intestine, the stomach, spleen, and pancreas were found in the 
left chest. The left lung was rudimentary. 

If inflation of the lungs by the catheter or otherwise is attempted, a 
sense of resistance is experienced. A physical examination of the chest 
shows that movement is limited to one side, the apex beat is far to the 
right, and usually there is tympanitic resonance over the left side. If a 
large deficiency in the diaphragm exists, infants usually survive but a few 
hours ; if a smaller one, life may be prolonged indefinitely. Northrup * 
has reported a case in a child who lived to the age of three years and pre- 
sented very obscure physical signs. It died from intercurrent disease, the 
only local symptom being marked dyspnoea. In this case several loops of 
the ileum, the caecum, and the vermiform appendix were found in the 
thoracic cavity. 

SCLEREMA. 

Sclerema is a condition characterized by hardening of the skin and 
subcutaneous tissues. It may occur in circumscribed areas or extend over 
nearly the entire body. It affects infants who are very feeble and usually 
terminates fatally. Although sclerema is chiefly seen in the first days of 

* Archives of Paediatrics, vol. ix, p. 130. 



SCLEREMA. 117 

life, it is not limited to the newly-born, but may occur at any time during 
the first few months. It is not to be confounded with oedema of the 
newly-born, with which condition it is, however, sometimes associated. 
From published reports it appears to be of not very infrequent occur- 
rence in Europe, chiefly in large foundling asylums. In America, sclerema 
is an extremely rare disease. In a discussion in the American Pediatric 
Society, in 1889, following the report of a case by Northrup, scarcely a 
dozen cases could be recalled by the members present. I have seen but 
five cases. In the newly-born, sclerema affects those who are premature 
or very feeble, sometimes those who are syphilitic. Later it may follow 
any condition leading to extreme exhaustion, especially the different forms 
of diarrhoeal disease. 

The first thing to attract attention is usually the induration of the 
skin. It is often seen first in the calves or the dorsum of the feet, some- 
times first in the cheeks, but soon extends over the greater part of the 
body. It is especially marked in the cheeks, buttocks, thighs and back, 
and regions where adipose tissue is abundant. It may affect the body uni- 
formly or in circumscribed areas. The skin may be smooth or it may ap- 
pear somewhat lobulated. The colour is normal or slightly bluish, often 
tinged with yellow. The lips are blue, and the capillary circulation so 
feeble that after pressure upon the nails the blood returns slowly or not 
at all. The limbs are stiff and board-like. The skin is cold to the touch, 
and often the thermometer in the axilla will not rise above 90° F. In 
cases reported by Eoger and Parrot, an axillary temperature of 71° F. was 
recorded. The general feeling of the body has been well likened by 
Northrup to that of a half-frozen cadaver. The tongue and the mucous 
membrane of the mouth are cold; no radial pulse can be felt; the respira- 
tion is slow, irregular, embarrassed, and at times the movements of the 
thorax are scarcely perceptible. The cry is a feeble whine, scarcely au- 
dible. The duration of the disease is usually from three to four days. 
Death occurs slowly and quietly. If recovery takes place there is gradual 
improvement in the circulation and nutrition, and, later, a disappearance 
of the areas of induration. 

The causes of sclerema are general, not local, the most important etio- 
logical factors being great feeblenesss, with lowering of the body tempera- 
ture, and, in consequence, hardening of the subcutaneous fat. If it be 
true, as stated by Langer, that the fat of childhood contains more pal- 
mitine and stearine than that of adults, it is easy to see how this may oc- 
cur. There are no essential lesions in this disease. Atelectasis is often 
present, and may have something more than an accidental association, as 
incomplete aeration of the blood is no doubt a factor in the production 
of the symptoms. In North rup's case, the skin after being injected was 
studied with great care microscopically, with absolutely negative results. 

The prognosis is very bad, because of the grave conditions of which it 



118 DISEASES OF THE NEWLY BORN. 

is the expression, but it is not invariably fatal. In its milder forms, 
where treatment is begun early, recovery may take place. The diagnosis 
is to be made from oedema by the fact that there is no pitting upon pres- 
sure, by the rigidity of the body, and by the great reduction in the tem- 
perature. The most important thing in treatment is artificial heat ; noth- 
ing but the incubator is efficient. In addition to this, care should be taken 
to promote the general nutrition by careful feeding and by all other 
means possible. 

(EDEMA. 

(Edema has often been confounded with sclerema, but, although they 
may sometimes exist together, the conditions are quite distinct. (Edema 
occurs in delicate infants, and is associated with a feeble heart, especially 
of the right side, in consequence of which there are insufficient aeration of 
the blood, overfilling of the veins, and often a lowering of the body tem- 
perature. It also depends upon poor blood states, like severe anaemia, and 
I have seen it occur after haemorrhages. The kidneys are unaffected. 

The swelling is first noticed in the eyelids, the dorsum of the feet, the 
hands, or in dependent parts of the body. It may come on quite sud- 
denly. In severe cases there may be general anasarca, but dropsy into the 
serous cavities is rare. Sometimes the first thing observed may be a sud- 
den increase in weight before the oedema of any part is striking enough 
to be noticed. The general condition is feeble ; the surface of the body 
cool ; the temperature often subnormal ; the cry weak ; the urine often 
scanty, but rarely albuminous. The diagnosis of oedema is quite easy, the 
parts having the same appearance as in older patients. They are soft and 
waxy-looking, and pit upon pressure. While in most cases the prognosis 
is unfavourable, the disease is not necessarily fatal, since some even of the 
severe cases recover. The usual duration is five or six days ; but there are 
frequently relapses. 

The object of treatment is first to promote the general nutrition by all 
available means, and then to improve the circulation by the administra- 
tion of heart stimulants, particularly digitalis and alcohol. In cases of 
extensive oedema, alkaline diuretics, like the citrate of potash, may be 
combined with digitalis. The body-temperature must be carefully main- 
tained by artificial heat. The principal complications are diseases of the 
lungs and of the intestines. 

INANITION FEVER. 

The term inanition fever is not altogether a satisfactory one ; but, 
until these cases are better understood, it is adopted because it empha- 
sizes the very close connection which exists between the rise of tem- 
perature and the condition of inanition or starvation. Under this head- 
ing are included cases seen during the first five days of life — generally 
from the second to the fourth day — in which there is an elevation of tern- 



INANITION FEVER. 119 

perature, apparently due to the fact that the infant gets very little, fre- 
quently nothing at all from the breast at which it is being suckled. It 
is further characteristic of these cases that the temperature falls when the 
milk is secreted in abundance, or when the child is put upon a full breast, 
or when artificial feeding is begun, or even when water is administered, if 
freely given. 

So far as my knowledge goes, the first to call attention to this condi- 
tion was McLane (New York), who in 1890 reported to one of the med- 
ical societies an extraordinary case of hyperpyrexia in a newly-born child. 
The infant was found on the sixth day with a temperature of 106° F., 
near which point it had remained for three days. The child was being 
suckled at a breast which was found to be absolutely dry. A wet-nurse 
was procured, the temperature fell to normal in a few hours, and the child, 
which when first seen was apparently in a hopeless condition, was soon 
perfectly well. 

Since that time very extensive observations, extending to upward of 
three thousand cases, have been made at the Sloane Maternity and Nurs- 
ery and Child's Hospitals, which have established the fact that a rise of 
temperature to 102° or even 104° F. is quite common in newly-born in- 
fants during the first few days. This fever is accompanied by no evi- 
dences of local disease, and ceases in nursing infants with the establish- 
ment of the free secretion of milk. The fall in temperature is often 
rapid, dropping to the normal in a few hours after having continued for 
three or four days, and in a large number of cases it does not rise again. 

The following case is a fairly typical one of the more severe form : 
The patient was the second child, the first having died at the age of 
ten days, from no disease it was said, but simply from exhaustion. At 
birth the infant, a boy, weighed eight and a quarter pounds and was 
apparently vigorous. During the first forty-eight hours his loss in weight 
was five and a half ounces and his condition good. I saw him on the 
evening of the third day. In the preceding twenty-four hours he had lost 
eight ounces in weight, and the temperature had gradually risen, until 
at the time of my visit it was 102*8° F. The body was limp, the child 
making no resistance to examination. He cried with a feeble whine ; 
the restlessness of the early part of the day having given place to complete 
apathy. The lips and skin were very dry, the fontanel sunken, the pulse 
weak. As the father, a physician, expressed it, " he had been wilting 
through the day like a flower in the sun." Although put to the breast 
regularly, the child had apparently got very little. It was, in fact, impos- 
sible to squeeze any milk from the mother's breasts. Water was freely 
given and a wet-nurse secured in a few hours. The first milk was taken 
from the wet-nurse at 11 p. m., and the.temperature, which fell gradually 
during the night, was normal the next morning and did not rise again. 
(See chart, Fig. 21). During the succeeding four days the child gained 



120 



DISEASES OF THE NEWLY BORN. 



eighteen ounces in weight, and at the end of a week was as well as an 
average infant of his age. 

The symptoms are so uniform and so characteristic that they make 
for these cases of fever a class by themselves. The frequency with which 
this is seen is shown by the following statistics : Among 200 infants taken 
successively at the Nursery and Child's Hospital, 20 had fever during the 
first five days, reaching 101° F. or over, which was not explained by 
ordinary causes and followed the course above described. In 500 suc- 
cessive children born at the Sloane Maternity Hospital, there were 135 
with a similar fever. It was seen in vigorous infants as well as in those 

who were delicate. The usual 
duration of the fever was three 
days, the temperature generally 
touching the highest point upon 
the third or fourth day of life. 
In about two thirds of the cases 
the temperature did not rise above 
102° F. ; in 9 it was 104° F. or 
over, the highest recorded being 
106° F. The fall was generally 
quite abrupt, although not always 
so. Daily weighings, which were 
made in these cases, showed that 
the infants continued to lose 
weight while the fever continued, 
and that the loss almost invariably 
exceeded by several ounces that of 
the children who had no fever. 
(See p. 16.) The maximum loss 
noted was twenty-eight ounces. In quite a large number of cases it ex- 
ceeded twenty ounces. As a rule the infants began to gain in weight when 
the temperature remained at the normal point, but not until then. 

The symptoms presented by these infants were a hot, dry skin, marked 
restlessness, dry lips, and a disposition to suck vigorously anything within 
reach. With very high temperature there were considerable prostration 
and weakened pulse. In the less severe cases there were only crying and 
restlessness. The rapidity with which the symptoms disappeared when 
the children were wet-nursed or properly fed, was very striking. 

It is important that this fever should be recognised, because it gives at 
times the first warning of a condition which may prove fatal. The extra 
loss of ten or fifteen ounces in the first week, is a serious handicap to 
newly-born infants, the effect of which may last for several weeks. The 
temperature of every child should be taken during the first week. All the 
usual local causes of fever are first to be excluded by a physical examina- 



102° 



101 c 



1C0" 



1234 5 078 








ft 


J] 


"T 


t 


-J = 


^T 


/ 


T X - 


/ 




-^ 


VJ 


— ^*^b;^v / s 


— 



Fig. 21. — Temperature chart. Inanition fever. 






INANITION FEVER. 121 

tion. This fever can hardly be confounded with that due to pyogenic 
infection, which rarely begins before the fifth or sixth day. 

The treatment is simple — viz., to give water regularly every two hours, 
in quantities up to an ounce at a time if required by the thirst of the 
child. This should be done in every case where the temperature reaches 
101° F. When the temperature does not at once begin to fall, the infant 
should be put upon another breast or artificial feeding should be begun. 
Examination of the breasts from which the child has been nursing will 
usually reveal the fact that the secretion of milk is very scanty and often 
entirely absent. 

Such a fever I have occasionally seen in older infants, usually in those 
who are nursing dry breasts or where fluid food and water have been with- 
held because of some gastric disturbance. It yields as promptly to treat- 
ment as does the same condition in the newly-born. 



SECTION II. 
NUTEITION. 

CHAPTER I. 
INTRODUCTORY. 

Nutrition in its broadest sense is the most important branch of 
paediatrics. At no time of life does prophylaxis give such results as in 
infancy, and no part of prophylaxis is worthy of more attention than the 
conditions of nutrition. This study is the first duty of physicians who 
practise among children. The importance of correct ideas regarding it 
can hardly be overestimated. The problem is not simply to save the 
child's life during the perilous first year, but to adopt those means which 
shall, during the plastic period of infancy, tend to the healthy and normal 
growth of the child, so that all the organs of the body shall have their 
normal development instead of impaired structure and deranged func- 
tion, the effects of which may last throughout childhood or even through- 
out life. 

The question whether a child shall be strong and robust or a weakling, 
is often decided by its food during the first three months. The largest 
part of the immense mortality of the first year is traceable directly to dis- 
orders of nutrition. The child must be fed so as to avoid not only the 
immediate dangers of acute indigestion, diarrhoea, and marasmus, but the 
more remote ones of chronic indigestion, rickets, scurvy, and general mal- 
nutrition with all its varied manifestations, since these conditions are the 
most important predisposing causes of acute disease in infancy. 

One of the difficulties has always been that temporary success may 
mean ultimate failure. If the injurious effects of improper feeding were 
immediately manifest, there would be very much less of it than exists at 
the present time. It is because many things are valuable as temporary 
foods, which when used permanently are injurious. No better illustration 
is seen than in the too exclusive use of carbohydrates, like most of the 
proprietary foods. Infants so fed grow very fat, and for the time appear 
to be properly nourished. The absence from the food of some of those 
elements which are of vital importance may not be evident for months ; 
hence the mistakes so often made by the laity, and even by the profession. 

122 



THE FOOD CONSTITUENTS— PROTEIDS. 123 

There are certain plain rules regarding the requirements of the growing 
organism which can not be ignored without serious consequences, which 
will sooner or later be evident. Another common mistake is in the pro- 
longed use of predigested foods. These are sometimes continued until, as 
in a case under my observation, a healthy child at two-and-a-half years was 
totally unable to digest the casein of cow's milk. A great stumbling-block 
to many is the fact that there are some infants of robust constitution who, 
in good surroundings, have thriven exceptionally well in spite of very bad 
methods of feeding. But it should not be forgotten that there are a very 
much larger number of perfectly healthy infants whose lives are sacrificed 
every year, both directly and indirectly, as a result of improper feeding. A 
method of feeding is to be judged not by the few exceptional cases which 
may do well, but by the results obtained in the majority of cases. 

Let no one think that he can secure the best results in infant-feeding 
without devoting both time and study to the problem. Close attention 
to details is indispensable to success in this as in all branches of medicine ; 
but in none are more satisfactory results obtained. 

THE FOOD CONSTITUENTS AND THE PURPOSES THEY SUBSERVE IN 

NUTRITION. 

In infancy and childhood, as in adult life, the elements of the food 
are five in number : proteids, fat, carbohydrates, mineral salts, and water. 
The form in which they must be furnished to the child, and the relative 
quantities in which they are demanded, are different from those required 
by the adult. One of the reasons for this difference is the delicate condi- 
tion of the organs of digestion in infancy, and the inability to assimilate 
certain forms of food. Another reason is that provision must be made 
not only for the natural waste of the body, but for its rapid growth, nearly 
trebling in size, as it does, during the first twelve months. 

Proteids. — The proteids are essential to life, since they constitute the 
only kind of food which is capable of replacing the continuous nitroge- 
nous waste of the cells of the body, upon the healthy condition of which 
the digestion and assimilation of the other elements of the food depend. 
Without the aid either of the fats or the carbohydrates, the proteids may 
sustain life and may even prevent a loss of weight for a time ; but in so 
doing a great excess of such food is required, as twenty-two parts of pro- 
teids can do the work of only ten parts of fat. Such a diet taxes severely 
the digestive organs and the kidneys. When, however, fat and carbohy- 
drates are added to the food, only one-half or one-third as much proteids 
are required to replace the nitrogenous waste, as in the case of an exclusive 
proteid diet (Munk). 

The proteids are furnished by the casein and the other albuminoids 
present both in woman's milk and cow's milk, in the white of egg, muscle- 



124 NUTRITION. 

fibre, gluten of wheat, etc. The proteids easiest of digestion by infants 
are those of woman's milk. The greatest difficulty in artificial feeding 
has been to supply other proteids which can take their place. It is the 
difference in the digestibility of the proteids that causes most of the 
trouble in the substitution of cow's milk for woman's milk. 

The average amount of proteids furnished in a good sample of woman's 
milk is 1-5 per cent. During the first few months, infants fed upon cow's 
milk should not receive a larger proportion than this, and on account of 
the difference in the digestibility of the two, the proteids of cow's milk 
must at first be reduced below this point, usually to 1 per cent, and in 
some instances to 0*5 per cent. Some infants fed upon milk appear to 
thrive normally for a considerable period, even with so small a proportion 
of proteids as 0*5 per cent, provided the other elements of the food are 
supplied in abundance. But all children fed on low proteids must be very 
closely watched. It is always hazardous to keep an infant long upon a 
food which is low both in proteids and fat. 

The most constant symptom following insufficient proteids in the 
food is anaemia. Besides this, there may be feeble circulation, loss of 
strength, flabbiness of the tissues, and general failure of nutrition. Later 
there may follow difficulty in the digestion of other elements of the food. 
The vegetable proteids can not permanently take the place of the animal 
proteids in the food of young infants. 

Fats. — As has already been hinted on the previous page, the uses of 
fat in the body are intimately associated with those of the proteids. Fat 
possesses the important property of saving nitrogenous waste, so that 
when this is supplied in the food in proper proportions^ the entire energy 
of the proteids may be expended upon the growth and nutrition of the 
cells of the body without being used up in the production of animal heat. 
The demands made upon the proteids by the rapid growth of the body in 
infancy, make it desirable that, whenever possible, the fats should do the 
work of the proteids. 

In addition to their use as a source of animal heat, the fats add to the 
body-weight by storing up fat in the body. They are needed for the 
growth of the nerve cells and fibres, and are essential to the proper growth 
of bone. Exactly what the part is which the fats take in the development 
of the osseous system is not altogether understood, but it is probable that 
their effect is due to their well-known and important function in aiding 
the absorption from the intestines of inorganic salts, especially the earthy 
phosphates. In a patient upon a milk diet, when the fats are withheld or 
greatly reduced, these salts appear in large quantities in the fasces. More 
fat is supplied in the food of the nursing infant than is used up in the 
body, as a very large amount is normally discharged in the stools. To 
this is due the soft consistence of the stools of the nursing infant. Fats 
thus seem to fill the role of a natural laxative ; constipation being one of 



CARBOHYDRATES. 125 

the first and most striking symptoms following the reduction of fat in the 
milk. 

The proportion of fat required in infancy, is therefore very much 
greater than at any other period of life. Probably the most common mis- 
take in artificial feeding has been to give too little fat. The chief reason 
for the failure of most of the proprietary infant-foods is that they are too 
low in fat ; but an excess of carbohydrates can not supply this deficiency. 

Woman's milk of a good quality contains from 3 to 5 per cent fat, and 
this may be taken as representing the needs of the body under normal 
conditions. Infants who are fed upon cow's milk should get, on the 
average, 3 per cent fat for the first few months and 4 per cent during the 
latter part of the first year. Infants who are fed for a long time upon a 
food low in fat are very prone to develop rickets. Clinical experience 
also teaches that if the food at the same time is low in proteids this result 
follows much more readily. As such a diet is in most cases excessive in 
carbohydrates, children so fed are apt to be very fat, but usually anaemic. 
The importance of fats in nutrition does not end with the first year; 
they should be supplied liberally throughout childhood. The most con- 
venient form of administration is cream, and next to this cod-liver oil. 

Carbohydrates. — Although these, like the fats, can not replace the 
nitrogenous waste of the body, they are important aids to the proteids, 
and in this respect they are even more valuable than the fats. The car- 
bohydrates are partly converted into fat, and may thus increase the body- 
weight. They are capable of replacing the fat-waste of the body. They 
are one of the most important sources of animal heat. 

Carbohydrates are the most abundant of the solid elements of the food, 
although they form a smaller percentage of the entire quantity of food in 
infancy than in adult life. The form in which carbohydrates are fur- 
nished to the infant, and in fact to all young mammals, is milk-sugar. 
While this form of sugar is to be preferred, it is by no means so essential 
that it be given as that the fat and proteids of the food should be those of 
milk. Other forms of sugar may often take its place without interfering 
with nutrition. Sometimes, when there is difficulty in the digestion of 
milk-sugar, a temporary change to cane-sugar or to maltose may even be 
advantageous. The carbohydrates required by young infants can not, ex- 
cept to a very small extent, be supplied in the form of starch, owing to 
the feeble diastatic power of the digestive fluids during the early months, 
and in fact during the greater part of the first year. As a rule, there is 
less difficulty in the digestion of the carbohydrates in the form of sugar 
than of any other part of the food. A diet consisting too exclusively of 
carbohydrates leads often to a rapid increase in weight, but it is not ac- 
companied by a proportionate increase in strength. Such infants have 
but little resistance, and many of them become rachitic. The easy diges- 
tion of a food consisting chiefly of soluble carbohydrates, and the rapidity 



126 NUTRITION. 

with which children so fed gain in weight, lead to a great misapprehen- 
sion in regard to their value as foods. The ultimate results of such one- 
sided feeding, if long continued, are almost invariably disastrous. 

In building up the cells of the body the proteids are first in impor- 
tance, the carbohydrates second, and the fats third. In the production of 
animal heat the fats come first, the carbohydrates second ; practically the 
proteids should never be called upon for this purpose. In a proper diet, 
all of these elements are represented. 

Mineral Salts. — These are of greater importance in infancy than later 
in life, because of the building up of the osseous system which is going on 
with such rapidity during infancy and early childhood. The most im- 
portant for this purpose are the phosphates of lime and magnesium. 
These are furnished in abundance both in woman's and cow's milk. 
These salts are also necessary for cell growth. The other inorganic salts 
furnish the elements from which the mineral constituents of the blood 
and digestive fluids are formed, and still others facilitate absorption, ex- 
cretion, and secretion. 

Water. — The food of all young mammals consists of from eighty to 
ninety per cent of water. This is needed for the solution of certain parts 
of the food, such as the sugar and some of the proteids, and for the sus- 
pension of the other proteids and the emulsified fat. All the food is thus 
dissolved or very finely divided so as to be more readily acted upon by the 
feeble digestive organs of the infant. Water is needed also in large quan- 
tities for the rapid elimination of the waste of the body. In proportion 
to its weight, an average infant during the first year requires a little more 
than six times as much water as an adult. During the time when the 
child is upon an entirely fluid diet, the addition of water other than that 
supplied by the food is unnecessary ; but when the number of feedings 
becomes less frequent, and solid food is given in larger quantities, water 
should be given freely between the feedings at all seasons, but especially 
in the summer. 



CHAPTER II. 
THE INFANT'S DIETARY. 

WOMAN'S MILK. 

Woman's milk is the ideal infant-food. A thorough knowledge of 
its character, exact composition, and variations is indispensable, for upon 
this knowledge are based all our rules for the preparation of foods used 
as substitutes for woman's milk when this can not be obtained. 



WOMAN'S MILK. 



127 



Woman's milk is a secretion of the mammary glands and not a mere 
transudation from the blood-vessels ; although under abnormal conditions 
it may partake more of the character of a transudation than a secretion. 
A few drops may be squeezed from the breasts before parturition ; gener- 
ally speaking, however, it is only present after delivery. During the first 
two days the secretion is scanty. Usually upon the third or fourth day it 
becomes well established, although it may be delayed until the fifth or 
sixth day. During the period of lactation, milk is constantly formed in 
the mammary glands, but the process, is more active while the child is at 
the breast. 

Physical Characters. — Woman's milk is of a bluish-white colour and 
quite sweet to the taste. When freshly drawn its reaction is usually alka- 
line, sometimes neutral, but under healthy conditions never acid. The 
specific gravity varies between 1,027 and 1,032, the average being 1,031 at 
60° F. On the addition of acetic acid only a slight coagulation is seen, 
this being in the form of small flocculi, and never in large masses as is the 
case in cow's milk. Microscopically, there are seen great numbers of 
fat-globules nearly uniform in size and some granular matter. Occasion- 
ally there are present epithelial cells from the milk-ducts or from the 
nipple. 

Colostrum. — The secretion of the first two or three days differs quite 
markedly from the later milk. To this the name colostrum has been 
given. It is of a deep yellow colour, which is chiefly due to the colostrum- 








-'Mag' 






Fig. 22.— Colostrum. (Funke.) 




Fig. 23. — Woman's milk at a late period. 
(Funke.) 



corpuscles. It is not so sweet as the later milk. It has a specific gravity 
of 1,040 to 1,046, a strongly alkaline reaction, and is coagulated into solid 
masses by heat, and sometimes coagulates spontaneously. It is very rich 
in proteids and in salts. Microscopically the fat-globules are of unequal 
'size, and there are present large numbers of granular bodies known as 
colostrum-corpuscles (Fig. 22). These are four or five times the size of 



128 NUTRITION. 

the milk-globules (Fig. 23), and they are probably epithelial cells which 
have undergone fatty degeneration. 

Composition of Colostrum* 

Proteids 5-71 

Fat 2-04 

* Sugar 3-74 

Salts 0-28 

Water 88 • 23 

100-00 

The colostrum-corpuscles are very abundant during the first few days, 
but under normal conditions they are not found after the tenth or 
twelfth day. 

Daily Quantity. — Exact information upon this point is difficult to 
obtain. There are recorded, however, extended observations made with 
great care upon five cases,f from which some deductions may safely be 
drawn. All were healthy infants, nursing exclusively and gaining steadily 
in weight. 

From these observations, and others less extended, the average daily 



* From five analyses by Pfeiffer of milk obtained during the first three days. 

f Haehner's cases (Jahrb. f. Kinderh., xv, 23 ; xxi, 314). Case I. Female ; birth- 
weight 7 pounds 14 ounces (3,100 grammes). First week, lost 1-J ounce (41 grammes) ; 
after this gained steadily during the twenty-three weeks of observation ; from second 
to ninth week, average weekly gain 8 ounces (241 grammes) ; from tenth to eighteenth 
week, average gain 4-£ ounces (138 grammes) ; from nineteenth to twenty-third week, 
average gain 4 ounces (130 grammes); weight at the end of twenty-third week, 14f 
pounds (6,690 grammes). 

Case II. Male ; birth- weight 6-| pounds (2,950 grammes). Loss, first week, 3 ounces 
(80 grammes) ; after this gained steadily during the eleven weeks of observation ; from 
second to eleventh week, average weekly gain 7£ ounces (214 grammes) ; weight at end 
of eleventh week, 11 pounds 2 ounces (5,045 grammes). 

Case III. Female; birth- weight 3 pounds 9 ounces (1,620 grammes). Gain, first 
week, 1-J ounce (40 grammes) ; during the succeeding twenty-one weeks of observation, 
average weekly gain of 5 ounces (141 grammes) ; weight at the end of twenty-second 
week, 10 pounds 3 ounces (4,620 grammes). 

Laure's case (These, Paris, 1889). Female; birth-weight 8 pounds 13 ounces (4,000 
grammes) ; loss, first week, 8 ounces (225 grammes) ; after this gained steadily during 
the nine weeks of observation, on an average 9| ounces (268 grammes) weekly ; at the 
end of ninth week, weight 13 pounds 3-£ ounces (6,000 grammes). 

Ahlfeld's case (Deutsch. Ztschr. f. Prakt. Med., 1878). Birth-weight 7 pounds 14 
ounces (3,100 grammes). Observations continued from fourth to thirtieth week. Dur- 
ing first ten weeks, average weekly gain 5f ounces (161 grammes) ; from eleventh to 
twentieth week, 7£ ounces (214 grammes) ; from twenty-first to thirtieth week, 6 ounces 
(168 grammes) ; at the end of thirtieth week, weight 18 pounds 9^ ounces (8,435 
grammes). 

In all these cases the amount of milk was determined by weighing the infant upon 



WOMAN'S MILK. 



129 



quantity of milk secreted under normal conditions of health may be as- 
sumed to be pretty nearly as follows : 



At the end of the first week 10 to 16 oz. 

During the second week 13 to 18 oz. 

During the third week 14 to 24 oz. 

During the fourth week 16 to 26 oz. 

From the fifth to the thirteenth week ... 20 to 34 oz. 

From the fourth to the sixth month 24 to 38 oz. 

From the sixth to the ninth month 30 to 40 oz. 



Approximately. 
(300 to 500 grm.). 
(400 to 550 grm.). 
(430 to 720 grm.). 
(500 to 800 grm.). 
(600 to 1,030 grm.). 
(720 to 1,150 grm.). 
(900 to 1,220 grm.). 



It will be noted that the amount increases very rapidly up to about 
the eighth week, and after this much more slowly. The amount of milk 
varies also with the demands of the child in a very striking and uniform 
way. 

A comparison of the daily amount of milk taken with the weight of 
the child at the different periods, shows that during the first ten weeks 
large children take on an average an amount equal to from fifteen to 
nineteen per cent of the body- weight ; while smaller children, during the 
same period, take only from twelve to fourteen per cent of the body- 
weight. From the eleventh to the thirteenth week the large children 
take daily from thirteen to seventeen per cent of the body- weight, and 
the small ones from eleven to thirteen per cent, showing that the larger 



very delicate scales both before and after every nursing during the entire period of ob- 
servation. 

The following table gives in a condensed form the daily quantity of milk in these 
cases : 



Time. 


Haehner's 
1st case. 


Haehner's 
2d case. 


Haehner's 
3d case. 


Laure's 
case. 


Ahlfeld's 
case. 


1st dav 


Grammes. 

20 
176 
265 
420 
360 
374 
423 
497 
550 
594 
663 
740 
880 
835 
766 
796 
807 
870 


Grammes. 

75 
135 
325 
295 
290 
340 
350 
423 
468 
531 
561 
661 
681 
730 
665 


Grammes. 

20 
45 
70 
99 
124 
136 
156 
229 
314 
379 
447 
472 
525 
568 
584 
600 
673 
709 


Grammes. 

125 

222 

400 

475 

500 

556 

730 

810 

944 

978 

1,038 

1.024 

1,085 


Grammes. 


2d day 


57( 




3d dav 




4th dav 




5th day 




6th day 




71 h dav 




Average 2d week 




Average 3d week 




Average 4th week 


i 


Average 5th week 

Average 6th week 


655 
791 


Average 7th week 

A verage 8th week 


811 
845 


Average 9th week 


810 


Average 10th to 13th week.. 
Average 14th to 17th week.. 
Average 18th to 23d week.. . 
Average 24th to 30th week . . 


861 

981 
1,021 
1,14. 


) 
) 



n 



130 



NUTRITION. 



children take not only more food, but more in proportion to their size 
than the smaller ones. 

The average quantity taken at one nursing by the five children previ- 
ously mentioned was as follows : 

Approximately. 

During the first week f to l-£ oz. (18 to 50 grm.). 

During the second week 1 to 3 oz. (30 to 90 grm.). 

During the third week H to 4 oz. (45 to 120 grm.). 

During the fourth week l£ to 4| oz. (45 to 140 grm.). 

From the fifth to the seventh week 2 to 5 oz. (64 to 150 grm.). 

From the eighth to the eleventh week 2£ to 5£ oz. (75 to 160 grm.). 

During the fourth month 3 to 6 oz. (90 to 180 grm.). 

During the fifth month 3^ to 6^ oz. (110 to 200 grm.). 

During the sixth month 4 to 7 oz. (120 to 220 grm.). 

Between the limits mentioned the greater number of cases will un- 
doubtedly fall. The amount taken at one time is, however, modified 
by the frequency of nursing, and is therefore not so good a guide to the 
amount of food required, as is the quantity taken in twenty-four hours. 

Composition. — Many of the older analyses of milk gave erroneous re- 
sults because of imperfect methods of examination. According to the 
most recent analyses of Pfeiffer, Koenig, Leeds, Harrington, and others, 
the composition of human milk is as follows : 





Average. 


Common healthy variations. 


Fat 


Per cent. 

4-00 
7-00 
1-50 
0-20 

87-30 


Per cent. 

3-00 to 5-00 


Sugar 


6-00 " 7-00 


Proteids 


1-00 " 2-25 


Salts 

Water 


0-18 " 0-25 
89-82 " 85-50 








100-00 


100-00 100-00 



In the older analyses, the percentage of proteids is almost invariably 
too high and the sugar too low. 

There are certain variations in composition depending upon the age 
of the milk. Nearly all these changes take place during the first month, 
and principally during the first two weeks. During this period there is, 
according to Pfeiffer, a fall in the proteids from nearly 4 to below 2 per 
cent, in the salts from 0-45 to 0-20 per cent, a rise in the sugar from 2 to 
6 per cent, and a very slight increase in the fat. After the first month 
the regular variations in composition are so slight that they may be prac- 
tically ignored. 

Proteids. — The proteids are not yet fully understood. Their separa- 
tion is somewhat difficult, and they are usually considered together. The 
most abundant and the most important ones are casein and lactalbumen, 
although Hammarsten gives a third — lactoglobulin — and some other au- 



WOMAN'S MILK. 131 

thors even a fourth. The casein is not in solution but in suspension, by 
virtue of the presence in the milk of lime phosphate, with which it is 
probably in combination. The lactalbumen is in solution ; it resembles 
serum-albumen. It is present in a larger proportion than in other varieties 
of milk. According to Koenig, lactalbumen is twice as abundant as casein. 

The proteids are usually present in the proportion of 1*50 to 2 per 
cent in woman's milk, although the variations are quite wide (1 to 4'5 per 
cent). The amount of proteids is larger in the milk of the first few days. 
After the third week the proportion changes but little during the whole 
period of lactation. 

Fat. — This exists in the form of minute globules, which are held in a 
state of permanent emulsion by the albuminous solution in which they 
are suspended. The old view, that the globules had an investing mem- 
brane, is now generally discarded. Like the proteids, the proportion of 
fat is subject to wide variations — 4 per cent being taken as the average. 
In thirty-four analyses made for me at the laboratory of the College of 
Physicians and Surgeons, the fat varied between 1-12 and 6*66 per cent. 
In forty-three analyses by Leeds, the variations were between 2*11 and 6-89 
per cent. The proportion is very little affected by the period of lactation. 

Sugar. — The sugar is in complete solution. Its proportion is very 
constant, the average being seven per cent. The ordinary variations are 
usually within the limits of 6 and 7 per cent. The sugar being so im- 
portant as a heat-producing element, Nature has wisely provided that this 
shall be the most constant ingredient of the milk. The amount of sugar 
is smallest in the milk of the first week ; after the first month, however, 
the variations are slight. 

Salts. — The average proportion of inorganic salts is 0*20 per cent, or 
about one fourth that of cow's milk. According to Eotch's analysis, the 
inorganic salts exist in the following proportions : 

Salts in Woman's Milk. 

Calcium phosphate ... 23*87 

Calcium silicate 1 • 27 

Calcium sulphate 2*25 

Calcium carbonate 2 • 85 

Magnesium carbonate 3 • 77 

Potassium carbonate 23 -47 

Potassium sulphate 8 -33 

Potassium chloride 12-05 

Sodium chloride 21-77 

Iron oxide and alumina 0-37 

100-00 

With the exception of calcium phosphate nearly all the salts are in 
solution. The milk of the first few days is very rich in salts — the propor- 



132 



NUTRITION. 



gar 




\ 



tion being fully twice that of any later period. After the first month the 
variations are slight. 

The Examination of Milk. — The exact composition of human milk is 
to be determined only by a complete chemical analysis. There are, how- 
ever, many variations which 
the physician may readily 
ascertain for himself by sim- 
ple methods of examination. 
The quantity of milk se- 
creted by the breasts may be 
estimated by the quantity 
which may be drawn by a 
breast-pump, although this 
is not a very reliable test. 
If the child nurses habitu- 
ally forty or fifty minutes, 
the probabilities are very 
strong that the quantity of 
milk is small. If the breasts 
at nursing time are full, hard, 
and tense, the supply is prob- 
ably abundant. If they are 
soft and flabby, and the 
milk appears to run in only 
while the child is nursing, it 
is almost certain that the 
quantity is small. The most 
reliable of all tests is weigh- 
ing the infant before and 
after nursing, upon an accu- 
rate pair of scales, sufficient- 
ly sensitive to indicate half- 
ounces. Two or three weighings will suffice to show conclusively whether 
an infant at three months, for instance, is getting habitually four or five, 
or only one or two ounces at a nursing. 

The reaction of milk may be taken with ordinary litmus paper. When 
freshly drawn it should be alkaline or neutral, never acid. 

The specific gravity may be taken with any small hydrometer gradu- 
ated from 1,010 to 1,040 (Fig. 24, B). The specific gravity is lowered by 
the fat, but increased by the other solids. An ordinary urinometer will 
answer every purpose, the only difficulty being the quantity which is re- 
quired to float the instrument. 

Microscopical examination. — The microscope reveals the presence of 
colostrum-corpuscles, blood, pus, epithelium, and granular matter. Colos- 



A B C 

Fig. 24.— Apparatus for examination of woman's milk. 
A, Marchand's tube ; B, C, the author's lactometer 
and cream-gauge. 



WOMAN'S MILK. 133 

trum-corpuscles are abnormal after the twelfth day ; pus and blood are 
always abnormal. All of these conditions necessitate the suspension of 
nursing, at least temporarily. But little importance can be attached to 
the size and appearance of the fat-globules as affecting the nutritive prop- 
erties of the milk. 

The determination of fat. — The simplest method is by the cream-gauge 
(Fig. 24, C), which is sufficiently accurate for ordinary clinical purposes. 
The glass cylinder holding ten cubic centimetres is filled to the zero mark 
with freshly drawn milk. This is allowed to stand at the temperature of 
the room (66° to 72° F.) for twenty-four hours, and the percentage of 
cream is then read off. Under these conditions, the relation of the per- 
centage of cream to that of fat is very nearly as five to three ; thus five 
per cent of cream will indicate that the milk contains three per cent of 
fat, etc. When an immediate determination of fat is desired, the most 
accurate instrument is the Babcock centrifugal machine. (See page 140.) 
Marchand's tube (Fig. 24, A) may also be employed. In this test the fat 
is extracted by ether and then precipitated by alcohol.* The various 
optical tests which have been suggested are much less satisfactory. 

Sugar. — The proportion of sugar is so nearly constant that it may be 
ignored in clinical examinations. 

Proteids. — We have no direct method for determining clinically the 
amount of proteids. If we regard the sugar and salts as practically uni- 
form, or so nearly so as not to affect the specific gravity, we may form an 
approximate idea of the proteids from a knowledge of the specific gravity 
and the percentage of fat. We may thus determine pretty positively 
whether they are greatly in excess or very scanty. The specific gravity 
will then vary directly with the proportion of proteids, and inversely with 
the proportion of fat — i. e., high proteids, high specific gravity ; high fat, 

* Marchand's test: First put in five cubic centimetres of milk, up to the line M; 
then four or five drops of liquor sodae ; shake ; add five cubic centimetres of ether, up to 
the line E; cork, and shake fifteen or twenty times; add ninety-per-cent alcohol, up to 
the line A. The tube is now tightly corked, shaken thoroughly, and placed upright in 
a tall bottle containing water at a temperature of 120° to 150° F. The fat separates 
and forms a distinct layer at the top, and after half an hour the amount is read off in 
degrees. By reference to the following table the exact percentage of fat is shown: 



Degrees Percentage 

Marchand. of fat. 



Degrees Percentage 

Marchand. . of fat. 



1 1-49 

3 1-96 

5 2-42 

7 2-80 

9 3-36 

11 3-82 

Each additional degree on the tube corresponds to 0'23 per cent of fat. To insure 
accuracy the test should be repeated two or three times with the same specimen. 
These tubes may be obtained from E. Greiner, 51 William Street, New York. 



13 4-29 

15 4-75 

17 5-22 

19 5-68 

21 0-14 



134 



NUTRITION. 



low specific gravity. The application of this principle will be seen by 
reference to the accompanying table.* 

Woman's Milk. 



Average 

Normal variations.. . 
Normal variations.. . 
Abnormal variations. 
Abnormal variations. 
Abnormal variations. 
Abnormal variations. 



Specific gravity 70° F. 



1-031 

1-028-1-029 

1-032 

Low (below 1-028). 
Low (below 1-028). 
High (above 1-032), 
High (above 1-032), 



Cream— 24 hours. 



7f„ 
8% - \2% 

High (above 10$), 

Low (below 5%). 

High. 

Low. 



Proteids (calculated). 



1'5% 

Normal (rich milk). 

Normal (fair milk). 

Normal or slightly below. 

Very low (very poor milk). 

Very high (very rich milk). 

Normal (or nearly so). 



The specimen taken for examination should be either the middle por- 
tion of the milk — i. e., after nursing two or three minutes — or, better, the 
entire quantity from one breast, since the composition of the milk will 
differ very much according to the time when it is drawn. The first milk 
is slightly richer in proteids and much poorer inJttat. The last drawn 
from the breasts is low in proteids and high in fat. The following analy- 
ses from Forster illustrate these differences : 





First portion. 


Second portion. 


Third portion. 


Fat 


Per cent. 

1-71 
1-13 


Per cent. 

2-77 
0-94 


Per cent. 

5-51 


Proteids 


0-71 







Conditions Affecting the Composition of Woman's Milk. — The age of the 

nurse. — This has no constant influence. Other things being equal, the milk 
of very young women, and also of those over thirty-five years of age, is likely 
to be lower in fat than that of women between twenty and thirty-five years. 

Number of pregnancies. — This has no constant influence except such 
as results from the effect upon the general health of the nurse. 

Acute illness. — In the majority of cases of acute illness of a minor 
character and of short duration there is no perceptible effect upon the 
milk. In the acute febrile diseases of a severe type the quantity of 
milk is reduced, the fat is low, and the proteids are apt to be high. In 
septic conditions bacteria may appear in the milk. 

Menstruation. — The effect of this is exceedingly variable, depending 
much upon the individual and the ease of menstruation. From observa- 
tions upon 685 cases, Meyer noted disturbances in the child in over one 
half the number. My own experience accords rather with that of 

* The authors apparatus for this examination, consisting of lactometer (Fig. 24, B) 
and two cylindrical graduated glasses (Pig. 24, C), may be obtained from Eimer and 
Amend, Eighteenth Street and Third Avenue, New York, With these the test can be 
made with half an ounce of milk. For a fuller discussion of the subject, see article by 
the author in Archives of Paediatrics, March, 1893. 



WOMAN'S MILK. 



135 



Pfeiffer and Schlichter, who consider it quite exceptional for the child to 
be visibly affected. Schlichter made observations upon infants during 
233 menstrual days, noting the condition of the stools and digestion both 
before and after menstruation. In ninety per cent of the cases there was 
no perceptible influence. In only eight per cent were the stools- bad, and 
in only three per cent was there disturbance of the stomach with vomiting. 
The nature of the changes in milk produced by menstruation is illus- 
trated by the following case taken from Kotch : 





Second day of men- 
struation. Bowels of 
child loose. 


Seven days after 

menstruation. 

Bowels regular. 


Forty days after men- 
struation. Child 
gaining rapidly. 


Fat 


Per cent. 

1-37 
6-10 
2-78 
0-15 
89-60 


Per cent. 

2-02 

6-55 

. 2-12 

0-15 

89-16 


Per cent. 

2-74 


Sugar 

Proteids 


6-35 
0-98 


Salts 


0-14 


Water 


89-79 







At the present time sufficient observations have not been made to show 
whether the differences noted in the above case — low fat and high proteids 
— are the rule where disturbances are produced during menstruation. 
Monti's examinations lead him to the conclusion that the fat is not con- 
stantly affected. It is safe to say that the changes are not uniform, and 
that in very many cases none of importance are produced by menstruation. 

Diet. — The fat and the proteids of the milk are much influenced by 
diet, the sugar but very little. A nitrogenous diet increases quite uni- 
formly both the fat and the proteids. A vegetable diet diminishes both 
the fat and the proteids. A starvation diet diminishes the fat, while the 
proteids may be diminished or increased ; if the latter, they are generally 
changed in character. An excessively rich diet increases the fat and usu- 
ally the proteids also. All fluids tend to increase the quantity of milk. 
Alcohol in the form of malted drinks, and malt-extracts increase the quan- 
tity of milk and the amount of fat. The effect of alcohol upon the proteids 
is not constant, but they are usually increased. The following table gives 
the result of analyses of the milk of two women in the New York Infant 
Asylum before, while taking, and after taking an alcoholic extract of malt : 



Case I : 
Fat 

Proteids. 
Sugar . . . 
Salts.... 
Case II : 

Fat 

Proteids. 
Sugar . . . 
Salts.... 



Without malt. 



Per cent. 

1-74 
1-93 

7-02 
0-20 

1-12 
1-57 
7-11 
0-19 



After taking 8 oz. malt 
daily for 10 days. 



Per cent. 

3-83 
1-58 
7-43 
0-17 

2-75 
2-34 
0-77 
0-17 



III. 

No malt for 7 days. 



Per cent. 

2-41 
2-95 
6-59 
0-19 

1-70 
1-26 
6-04 
0-18 



136 NUTRITION. 

The child of Case I gained one ounce and a half during the four days 
preceding the first analysis ; that of Case II did not gain at all. During 
the ten days while taking the malt, the first child gained twelve ounces, 
the second child eight ounces. During the seven days after the malt was 
discontinued, the first child gained eight ounces, the second child one 
ouuce. There was a notable increase in the .quantity of milk in both 
cases while taking the malt. 

Klingemann has shown that the taking of alcohol of a poor quality 
(especially amylic alcohol) may cause it to appear in the milk, and may 
produce symptoms in the nursing infant, particularly if the amount taken 
is large. Seibert has called attention to very grave symptoms in infants 
produced by the ingestion of stale beer by nurses. 

The nursing woman should have a generous diet of simple food, and 
should drink largely of milk or gruels made with milk. The diet should 
be a varied one, not excessive in nitrogenous food nor in vegetables. All 
salads and highly seasoned dishes should be avoided, not so much because 
they upset the child, although this may happen, as because they are likely 
to disturb the digestion of the nurse. All the common vegetables and 
fruits in season may be allowed in moderation. Strong tea and coffee 
should be prohibited, although weak tea or coffee may be allowed, each 
but once a day. Cocoa is less objectionable than either tea or coffee. In 
addition to her regular meals the nurse should have milk or gruel at bed- 
time. The diet should in all cases be adapted to her digestion. Great 
harm often results from over-feeding with its consequent indigestion.. 
The taking of alcohol should be discouraged and its routine use for- 
bidden. 

Drugs. — The elimination of drugs through the milk is somewhat un- 
certain and variable. A large proportion of those popularly supposed to 
influence the child when taken by the nurse, have no effect whatever. 
The effect of drugs is more noticable when the milk is very poor in 
quality ; it being at such times more of an excretion than a secretion. 
This is seen during the early colostrum period, also during the illness of 
the nurse or when from various causes, mental or physical, the secretion 
becomes disturbed. The more important drugs affecting the child through 
the milk are the following : 

Belladonna : Effect quite constant under all circumstances when given 
in full doses. 

Opium : Effect inconstant, although it is possible, when the milk is 
poor, for toxic symptoms to be produced when full doses are given to the 
mother. A fatal case is on record in a child a few days old. 

Potassium iodide : Effect not uniform, particularly seen when the ad- 
ministration is long continued. Koplik and others have reported the pro- 
duction of iodism in nursing infants while the drug was taken by the 
mother. 



COW'S MILK. 137 

Bromides : Effect similar to that of the iodides. 

Mercury : Effect very feeble, and only after prolonged administra- 
tion.* 

Drugs occasionally eliminated in milk in sufficient amount to produce 
visible effects are the saline cathartics, arsenic, and the salicylates. Acids, 
chloral, and most other drugs are without effect. 

Pregnancy. — The milk of pregnant women is generally small in 
quantity and poor in quality, especially in fat. (See chart, p. 168). It is 
not known, however, that there are any other differences. 

Bacteria. — Under normal conditions human milk is practically sterile. 
In disease of the mammary gland of a suppurative character, bacteria are 
frequently found in the milk. They may also appear in considerable num- 
bers during puerperal sepsis. In the milk of women suffering from acute 
fevers not of septic origin, Escherich found no bacteria. It has been 
shown that the bacilli of anthrax and tuberculosis may appear in cow's 
milk apart from any disease of the udder itself. This may fairly be as- 
sumed to be true in the case of human milk. 

Nervous impressions. — These, when of a marked character, have a very 
decided and immediate effect upon the milk. Fatigue, exhaustion, great 
excitement, sudden fright, grief, or passion are likely to affect the secre- 
tion in a most marked manner. An infant who takes the breast under 
such circumstances may exhibit only the ordinary signs of acute indiges- 
tion, such as vomiting and undigested stools, or there may be in addition 
high temperature, great prostration, toxic symptoms, and sometimes even 
convulsions. The nature of the changes in milk from such causes is as 
yet but little understood. The probability is, however, that it is the pro- 
teids which are at fault, as these are very unstable and easily affected, and 
that instead of the normal proteids others are produced which possess 
toxic properties. In certain cases the secretion of milk may be almost 
entirely arrested by nervous influences. 

COW'S MILK. 

The only one of the lower animals whose milk is practically available 
for infant-feeding is the cow. Cow's milk being our main reliance in the 
artificial feeding of infants and the staple food of nearly all young chil- 
dren, it follows that everything relating to its production and handling is 
of great importance to the physician, In the feeding of children no one 
thing is more essential than a supply of pure cow's milk. Milk undergoes 
changes from such slight causes, that the physician should insist upon it 
that those who furnish milk for infant-feeding, whether in city or country, 
should be fully informed regarding this subject. In towns and cities phy- 

* See Fehling, Arch, fur Gynak., Bd. xxvii, II. 3. 



138 NUTRITION. 

sicians should co-operate to secure it for their patients in its best form.* 
The conditions to be fulfilled in good cow's milk are : 

1. It must be fresh. There are certain changes which take place in 
cow's milk, even when handled in the best manner, during the twenty- 
four or seventy-two hours which often elapse between the time it is drawn 
from the cows and its consumption. These changes, although perhaps 
not actually causing disease, may still interfere with the digestibility of 
milk, particularly by very young infants. It is entirely practicable in 
every city and town for milk to be obtained for young infants before it is 
twelve hours old, and this should be insisted upon. 

2. It must be from healthy animals. All herds furnishing milk for 
infant-feeding should receive the tuberculin test ; they should be subjected 
to careful and regular medical inspection. 

3. Preferably it should be the milk from a mixed herd rather than 
from a single cow. A milk is thus secured which is practically uniform 
in its composition, while that from a single cow may be subject to a con- 
siderable variation from day to day. A child fed upon the milk of a sin- 
gle cow is not infrequently made ill from changes in the milk, the result 
of food, temporary indisposition or other disturbance of the animal. f If 
the milk is the mixed product of several cows such a result is very much 
less likely to occur. 

4. The milk must be clean. This is only to be accomplished by a 
dissemination of knowledge among dairymen in regard to the common 
sources of milk contamination. It is to be secured by more rigid cleanli- 
ness in the stables, in the animals themselves, in the hands of the milker, 
in pails, cans, bottles, and all utensils with which the milk comes in con- 
tact. The amount of filth — dirt, hair, etc. — which is removed from ordi- 



* As an illustration of what can be accomplished in the way of securing a proper 
milk supply for the use of infants, the work of the Medical Commission of Newark, 
N. J., may be cited. This commission, organized largely through the efforts of Dr. 
H. L. Coit, has entered into an agreement with a dairyman, the terms of which are 
that the selection of the cows, the details regarding their food and care, and the 
handling of the milk shall be under the supervision of the Medical Commission. All 
these matters are carried out according to the most improved methods. The animals are 
subjected to a regular inspection by a competent veterinary surgeon; a chemist and 
bacteriologist are employed to see that the milk is kept up to the standard both as re- 
gards composition and purity. In return, the milk, which is delivered only in bottles, 
is stamped with the approval of the commission as "certified milk," and is sold at a 
slightly higher price than ordinary milk. Although in operation now but a short time, 
this plan has proved eminently successful both from a medical and commercial stand- 
point. If in every city and large town physicians would co-operate in this or some 
similar way, great good would be accomplished. 

\ It is well known that the milk of a cow during the " bulling " period may be the 
cause of very severe attacks of indigestion in infants who get such milk as their prin- 
cipal or only food. Such milk apparently contains some toxic products. 



COW'S MILK. 



139 



nary milk by passing it through a separator is simply appalling, and 
shows how carelessly most of our milk is handled at the present time. 
Bacterial contamination will be considered later. 

5. The animals should have fresh food, and not brewer's grains, which 
they are so likely to have in the neighbourhood of large cities. 

6. Transportation should be as short as possible, in order to secure 
freshness and to diminish the liability to the other changes which occur 
when milk is carried long distances.* The milk should be cooled, then 
bottled and sealed at the dairy, and kept at a temperature at or below 
45° F., until it reaches the consumer. In this way all chances of con- 
tamination by handling after the milk leaves the dairy are avoided. 

Composition. — The following table f gives the composition of milk from 
different breeds of cows: 





Durham. 


Ayrshire. 


Holstein. 


Jersey. 


American 
grades. 


Common 
natives. 


Fat 


Per cent. 
4-04 
4-34 
4-17 
0-73 

86-72 


Per cent. 
3-89 
4-41 
4-01 
0-73 
86-96 


Per cent. 
2-88 
4-33 
3-99 
0-74 

88-06 


Per cent. 
5-21 
4-52 
3-99 
0-71 
85-57 


Per cent. 
4-01 
4-36 
4-06 
0-74 
86-83 


Per cent. 
3-69 


Sugar 


4-35 


Proteids 

Salts 


4-09 
0-73 


Water 


84-14 







It will be seen that the averages are remarkably uniform in all the con- 
stituents except the fat, the variations here being between 2*88 and 5 "21 
per cent. Leaving out the Jerseys, the following represents very closely 
the average composition of cow's milk, as the physician has to do with it 

in infant-feeding : 

Average Cow's Milk. Per cent. 

Fat 3-50 

Sugar 4-30 

Proteids 4-00 

Salts 0-70 

Water 87'00 

100-00 

As to the relative advantages of the different breeds for infant-feeding, 
the difference has not seemed to me to be very great, provided all are 
equally healthy. It should be remembered that tuberculosis is rather 
more common in Jerseys than in other breeds. Practically it is necessary 
that the physician should know only the amount of fat in the milk he is 
using, as this is the variable factor. 



* Very much of the milk consumed in New York has been transported one hundred 
miles, and some is even brought three hundred miles. 

f These figures are compiled from over one hundred and forty thousand analyses, 
and have been collected by Mr. Gordon, of the Walker-Gordon Milk Laboratory ; sixty 
thousand of these analyses refer to the American grades and the common natives. 



140 



NUTRITION. 



Fat 

7 



4 cc. 



The Examination of Cow's Milk. — For clinical purposes the reaction, 
specific gravity, and percentage of fat should be determined. The normal 
reaction of cow's milk is neutral or slightly acid ; it should never be 
strongly acid. If it is strongly alkaline it is pretty certain that something 
has been added to it. The specific gravity is from 
_JP==^ 1,028 to 1,033. If the milk has been falsified by 

the removal of cream, the specific gravity is raised. 
The best of all ready methods of determining fat 
is the Babcock centrifugal machine.* By this the 
fat is brought to the surface by the centrifugal 
process after destroying the nitrogenous matter by 
sulphuric acid. This test is very accurate and can 
be made in five minutes. For institutions such an 
apparatus is indispensable; several specimens can 
be examined at the same time, and the composition 
of the milk and cream used can be determined each 
day. The optical test by means of Feser's lacto- 
scope (Fig. 25) is a good one, and with a little ex- 
perience in the use of the instrument is quite ac- 
curate, f 

The cream-gauge (Fig. 24, C) may be used as 
for woman's milk, but it is not very accurate. The 
milk while warm from the cow should be put into 
the cylinder and cooled rapidly by being placed in 
ice water. Under these conditions, if the reading 
is made at the end of eight or ten hours the per- 
centage of cream to that of fat is about four to one. 
If the milk has been first cooled and afterward 
handled two or three times before the test is made, 
the cream rises much less regularly and the above 
ratio is not maintained. 
The Differences between Cow's Milk and Woman's Milk. — The colour 
of cow's milk is more opaque than woman's milk, although the latter may 



Fig. 25. 



-Feser'i 
scope. 



lacto- 



* This can be obtained of any dairy-supply house in the country. 

f The test is applied as follows : Four cubic centimetres of milk measured in a 
pipette is put into the tube and water slowly added, shaking from time to time 
until the black lines on the porcelain stem "A " are faintly visible through the milky 
water. The percentage of fat is then read off on the glass cylinder at the level of 
the water added. Thus, water up to the mark " 4 " indicates four per cent fat, etc. 
This test is not to be applied to human milk. For cow's milk it is pretty satisfac- 
tory if the instrument is carefully made. A little experience is necessary in order 
to know exactly at what point of translucency the reading is to be taken. The lacto- 
scope may be obtained from Eimer & Amend, Eighteenth Street and Third Avenue, 
New York. 



COW'S MILK. 141 

contain the larger proportion of fat. This is due to the fact that the 
colour of the milk depends not only, upon the fat but also upon the cal- 
cium phosphate with which the casein is combined. This is so much 
more abundant in cow's milk than in woman's milk that even after the 
fat has been removed from the former, it is still of a deep white colour, 
while woman's milk under the same conditions is almost transparent. 
The total solids are usually greater in cow's milk, but the difference is 
slight. The sugar, as in woman's milk, is lactose in complete solution. 
At the present time there are not known to be any important differences 
in the fat. 

The most striking variation is seen in the proteids. Not only are the 
proteid substances in cow's milk from two to three times as great in 
amount, but they differ also in their character. The amount of proteid 
substances in cow's milk coagulable by acid is about four times as great as 
the non-coagulable portion ; while in woman's milk the non-coagulable 
portion is twice as great as the coagulable portion (Leeds). This is due 
to the fact that in cow's milk there is much more casein than lactalbumin, 
while in woman's milk there is less. This variation is shown most strik- 
ingly by the physiological test — its digestibility by the infant's stomach. 
Cow's milk in the stomach is coagulated into larger, firmer clots which 
dissolve slowly ; woman's milk into loose, flocculent curds, which dissolve 
readily. 

The inorganic salts of cow's milk are more than three times as abun- 
dant as those of woman's milk. In the composition of these salts the most 
important difference is that there is present in cow's milk a relatively 
larger proportion of calcium phosphate and sodium chloride with a 
smaller proportion of potassium chloride. 

The Salts of Cow's Milk (Weber and Fleischmann). 

Potassium 17'34 to 24-50 

Sodium 7-00 to 11-00 

Calcium 17-30 to 27*00 

Magnesia 1-90 to 4-07 

Iron oxide • 33 to • 62 

Phosphoric acid 20-00 to 29-13 

Sulphuric acid . 0*05 to 1-00 

Chlorine 15*6 to 16-34 

The reaction of cow's milk is neutral or slightly acid, practically never 
alkaline ; woman's milk is neutral or alkaline. 

Cow's milk as used always contains a large number of bacteria, which 
increase directly in proportion to the age of the milk ; the milk of healthy 
women is practically sterile. 

Cream. — A great misapprehension exists as to its composition. It is 
often spoken of as if it were entirely different from milk. It should 
rather be regarded as a milk which contains an excess of fat. 



142 



NUTRITION. 



Cream is obtained either by skimming — the gravity process — or by the 
use of a centrifugal machine known as a separator. The latter pro- 
cess has the advantage in point of time, as centrifugal cream can be 
put upon the market from twenty-four to thirty-six hours earlier than 
gravity cream. It is, however, attended by a slight disadvantage, as it 
may break up mechanically some of the fat-globules, so that after heating 
they may form a thin oily layer at the top of the bottle. This is more 
likely to occur where centrifugal cream has been transported a long dis- 
tance. 

The following table gives the composition of an average milk and of 
centrifugal cream of different densities removed from the same milk : 





Whole milk. 




Cream. 








I. 


II. 


in. 


rv. 


Fat 


4-00 
4-30 
4-00 
0-70 


8-00 
4-30 
3-90 
0-70 


12-00 
4-20 
3-80 
0-64 


16-00 
4-00 
3-60 
0-60 


20-00 
3-80 
3-20 
0-55 




Sugar 




Proteids 




Salts 










These will be spoken of hereafter as 8-per-cent cream, 12-per-cent cream, 
16-per-cent cream, etc., as indicating the amount of fat which they 
contain. The richest centrifugal cream contains from 35 to 40 per 
cent fat. 

From the table it will be seen that cream differs from the milk from 
which it is taken mainly in containing more fat. The reduction in the 
proteids, even in the 20-per-cent cream, is less than 1 
per cent. The changes in the other constitaents are so 
slight that they may be ignored. In common speech the 
term cream is applied to any of these. The physician 
should know, if he is using cream for infant-feeding, the 
approximate amount of fat it contains. The 40-per-cent 
cream is the very thick, centrifugal cream sold in cities ; 
20-per-cent cream is the ordinary centrifugal cream ; 16- 
per-cent cream is the common skimmed or gravity cream. 
In infant-feeding it is convenient to make use of a cream 
containing 12 per cent fat, and one containing 8 per cent 
fat. They may be obtained directly from fresh milk by 
the gravity process. If one quart of average milk is put into a glass 
jar and this into ice water or upon ice, after four or five hours there 
may be taken from the top about ten ounces of 8-per-cent cream ; 
after six hours, about six ounces of 12-per-cent cream (Fig. 26). Both 
of these may be removed by skimming, or, better still, the milk from 
the bottom of the jar may be siphoned off, leaving the amount men- 



Fig. 26.— Twelve 
per-cent cream. 



COW'S MILK. 



143 



tioned.* If the milk is richer than the average the time may be short- 
ened to three and five hours respectively. If it is poorer than the average 
the time must be lengthened. 

None of the methods described for determining the quantity of fat in 
milk are applicable to cream, except the Babcock centrifugal machine. 

Milk Sterilization. — The term sterilization is widely and rather 
loosely used to signify the heating of milk for the destruction of germs. 
It should, however, be borne in mind that none of the methods commonly 
employed renders milk sterile in the bacteriological sense of the word, 
although this can be done by heating milk on two or three successive days 
as in preparing culture media. What is accomplished by the means com- 
monly employed, is the destruction of such pathogenic germs as may be 
present, and a large number of the other bacteria, so as to retard for 
several days the ordinary fermentative changes. The preservation of milk 
for infant-feeding, by boiling it in small bottles, was advocated by Jacobi 



* A similar plan on a large scale may be followed in institutions by using an appa- 
ratus known as the " Cooley creamer." This consists of a wooden tank lined with 
metal, made of different sizes, holding two, four, or more cans of milk. The cans (Fig. 
27) hold eighteen quarts, and are 
so covered .that they can be sub- 
merged. The bottom of the can 
is inclined, and at the lowest 
point is placed a faucet. In the 
side is a glass window, so that 
the cream level can be distinctly 
seen. The cans are filled and 
placed in the tank of ice water ; 
after six or twelve hours the 
lower portion is drawn off and 
the upper creamy layer left be- 
hind. In this way a cream of 8, 
12, or 16 per cent may be ob- 
tained. The 8 and 12 per cent 
are those most convenient to 
use. If the milk is put in before 
the cream has risen once, after 
twelve hours from six to nine 

quarts of 8-per-cent cream may be obtained, and from four to six quarts of 12-per-cent 
cream; the variation being due to the difference in the milk employed. After six 
hours about two-thirds of the quantities mentioned can be obtained. The exact amount 
can be determined after a few experiments with any given milk by testing the strength 
of the cream each day with the Babcock machine. Then, with the same conditions of 
time, temperature, etc., the results will be quite uniform. If the milk is so old that 
the cream has already risen once, different results from those mentioned will be ob- 
tained. The plan is a simple one, involves very little trouble, and the milk during the 
time the cream is rising is kept at a low temperature. 

The Cooley creamer may be obtained at Bellows Falls, Vt. 




Fig. 27.— Cans of the Cooley creamer. 
B, section view. 



A, external view ; 



144 



NUTRITION. 



many years ago. The adoption of systematic means for the destruction 
of germs in milk for infant-feeding has been largely due to the work of 
Soxhlet. 

The most important of the germs in milk are the various saprophytic 
bacteria upon which are believed to depend a very large proportion of 

our diarrhceal diseases, the bacillus tuber- 
culosis, which may be derived from the 
cow or may be an accidental contamina- 
tion, and the germs of cholera, diphtheria, 
typhoid, and scarlet fever. All these 
flourish in milk at its ordinary tempera- 
ture. There is pretty conclusive evidence 
that outbreaks of all the diseases men- 
tioned have in certain cases been due to 
contaminated milk.* 

Following Soxhlet, all the earlier ex- 
periments in sterilization were made at a 
temperature of 212° F., continued for an 
hour and a half. So far as destroying 
germs was concerned this was quite enough. 
Such milk will keep for more than a week 
at ordinary room-temperatures. But it 
was soon found that some objectionable 
changes take place. The taste is that 
of boiled milk, to which many children 
strongly object; a certain proportion of 
the sugar is converted into caramel, causing a change in colour to a 
light brown ; the casein is rendered less coagulable by rennet, and is 
acted upon more slowly and imperfectly both by pepsin and pancrea- 
tin. Certain changes probably take place in the fat also. Children fed 




Fig. 28.— The Arnold sterilizer. 



* The degree to which contamination takes place under ordinary circumstances 
may be judged from the investigations of Sedgewick and Batchelder in Boston in 1892. 
In fifteen specimens of ordinary country milk which were handled in the usual way 
and examined a few hours after it was drawn from the cow, the average number of 
bacteria to each cubic centimetre (about fifteen minims) was 69,143. The average 
number in fifty-seven samples of market 'milk as delivered from wagons in the spring 
of the year was 2,355,500. In sixteen samples of milk as sold by grocers — this being 
several hours older than the milk delivered from wagons — the average number of 
bacteria to each cubic centimetre was 4,577,000. 

The principal source of contamination is undoubtedly from the cow and the stable 
during the process of milking. Dr. R. Gr. Freeman exposed for two minutes a Petri 
gelatin plate under a cow during milking and obtained 1,800 colonies. No doubt a 
great proportion of these germs are harmless, but with them others are often found 
which, if not strictly pathogenic, hasten fermentative changes in milk and greatly 
interfere with its digestibility. 



COW'S MILK. 145 

upon " sterilized " milk are certainly more prone to constipation than 
others, this probably depending upon the difficulty in digesting the 
casein. There seems now to be little doubt that the nutritive properties 
of the milk are, to a certain degree at least, impaired by heating to 212° 
F. for an hour and a half. In a large city, with the milk supply which is 
available, it may be in summer a choice of evils whether infants shall be 
fed upon " sterilized " milk, with the disadvantages mentioned, or whether 
by giving contaminated raw milk we shall run the risk of introducing 
germs which produce diarrhoeal diseases. The latter is certainly by far 
the greater danger. 

The changes mentioned as occurring in milk are believed to begin at 
or about 180° F., and to be more marked the higher the temperature is 
carried and the longer it is maintained. Heating milk to 212° F. for an 
hour or an hour and a half, should be employed only in the hot weather 
and when it is necessary to keep the milk for a considerable time as in 
travelling, or when ice is out of the question, as among the very poor. 

This method of heating milk is accomplished by the use of some ap- 
paratus by which steam is produced, the bottles being exposed on all 
sides in a close vessel. Probably the simplest and most satisfactory ster- 
ilizer is the " Arnold " (Fig. 28). 

" Sterilizing " at a Low Temperature — Pasteurizing Milk. — To obviate 
the objections above referred to, the practice has come largely into use of 
raising the temperature only to 167° F. This is known as " Pasteurizing," 
and has been extensively used in and about New York and in Boston. 
The temperature of 167° F., maintained for twenty minutes, has been 
shown to be sufficient to destroy the bacilli of cholera, typhoid fever, 
diphtheria, tuberculosis, bacterium coli commune, and the ordinary pyo- 
genic germs. It does not, however, destroy spores, and milk thus treated 
will keep at ordinary room-temperatures for two or three days only, but 
on ice for several days. A simple apparatus for this purpose (Fig. 29) * 
has been devised by Freeman, of New* York. In this the temperature is 

* Freeman's apparatus is used as follows : The pail is rilled to the groove with 
water, which is then raised to the boiling point. The bottles of milk are dropped into 
their places in the cylindrical cups, sufficient water being poured into each cup to sur- 
round the bottle, this water acting as the conductor of heat. The pail is now removed 
from the stove and placed upon a board or other non-conductor, and the receptacle con- 
taining the bottles of milk is set inside and the cover replaced. The volumes of milk 
and water have been so calculated that in ten minutes they are both at a temperature 
of about 167° F. The water contains heat enough to maintain this, with very slight 
variations, for twenty minutes. In half an hour the bottles of milk are removed and 
cooled rapidly by being placed in a water-bath, the water being changed once or twice; 
or, better, by setting the pail in a sink and allowing the cold water to run from a faucet 
through a piece of rubber pipe into the pail, overflowing into the sink. This rapid 
cooling is very important. They are then put in the refrigerator. This apparatus may 
be obtained from James Dougherty, 411 West Fifty-ninth Street, New York. 
1.1 



146 



NUTRITION. 



raised by hot water, while cold water is used as the conducting medium. 
Milk heated to 167° F. has no objectionable taste, and according to Free- 
man's experiments with artificial digestion, the character of the curd and 
its digestibility do not differ from that of ordinary milk. This seems to 
be borne out by clinical observation. 

The objections urged against heating to 212° F. do not hold against 
heating to 167° F., as most of the changes are thus avoided. However, 
the real question is whether there are any changes produced in milk so 
treated which detract from its value as an infant-food. Upon this point 
we must as yet speak somewhat guardedly, for experience with it is limited 





Freeman's Pasteurizer. A, bottles in position for heating ; B, method of cooling. 



to a few years. To my knowledge, no sufficient evidence has yet been 
adduced to establish the fact that milk so heated has lost any of its essen- 
tial nutritive properties, or that children fed exclusively upon it exhibit 
signs of either of the two most marked disorders of nutrition — rickets or 
scurvy; although I have seen two cases in which scurvy seemed to be 
clearly due to the use of milk heated to 212° F. for over an hour. 

It should be distinctly understood that sterilized milk requires the 
same modifications for infant-feeding as plain milk. There is no evidence 
to show that its nutritive properties or its digestibility are in any way 
enhanced by the process of heating. A great misapprehension seems to 
exist in the minds of many physicians with reference to this point. The 
opinion has gained a certain amount of currency that, if milk has only 
been " sterilized," it may be fed to a young infant without any further 
modification. 

The sterilization of milk is not a therapeutic measure of much value 
in the gastro-enteric diseases of infancy. It is capable of causing just 
about as much disturbance as plain milk given in the same circumstances. 
Its chief value — and I think I may say almost its only value — is in pre- 
venting disease, first, by enabling us to feed infants upon milk in which, 
although it may be forty-eight hours old, no considerable fermentative 



COW'S MILK. 147 

changes have taken place, and, secondly, by destroying pathogenic germs 
with which the milk may have become accidentally contaminated. 

The danger of transmitting tuberculosis to the infant by means of 
cow's milk is one that has, I think, been very greatly exaggerated. Ani- 
mal experiments show that this is certainly possible, and there are a few 
isolated instances on record in which this seems to have been the mode 
of infection in children, but these cases are extremely rare. In one hun- 
dred and nineteen autopsies of my own upon tubercular patients, nearly 
all of them infants, there was not found one with the primary lesion in 
the gastro-enteric tract. Northrup, in his large post-mortem experience, 
has seen but a single case. The danger of transmitting diphtheria, scarlet 
fever, and especially typhoid fever, by means of milk, is very much greater. 

Summary. — Prolonged heating to 212° F. is objectionable and is not 
to be recommended for general use. It may be necessary especially in 
cities and in very hot weather, where ice is scarce and the milk very 
highly contaminated, also when the milk is to be kept for several days, as 
while travelling; for prolonged journeys, however, such as crossing the 
ocean, the milk should be heated to 212° F. for one hour on three suc- 
cessive days. Heating to 167° F. is quite sufficient for ordinary purposes. 
It is desirable that milk thus treated should be prepared daily, although 
it will keep on ice for four or five days. The fewer the germs in the 
milk at the time of heating, the shorter the time and the lower the tem T 
perature which will be necessary, hence the desirability of having the 
milk as clean and as fresh as possible. For the best results, the heating 
should be done at the dairy, so that the antecedent changes shall be reduced 
to the minimum. Without this precaution these changes are sometimes 
so great as to render the milk unfit for use. Heating milk for purposes 
of sterilization is at present imperative in cities during the warm months, 
as ordinary milk is from twelve to thirty-six hours old when received, 
and from twenty-four to seventy-two hours old before it is consumed. 
In the country it is a safeguard to be used when doubt exists in regard to 
the health of the cows or the handling of the milk ; but where clean milk 
can be obtained fresh every morning from healthy cows, it is unnecessary. 
"Sterilized" milk requires the same modification for infant-feeding as 
plain milk. " Sterilization " is not to be regarded as a therapeutic meas- 
ure ; its value consisting in the prevention of disease. While I advise and 
constantly use milk which has been heated, my preference is strongly for 
that which is sufficiently pure, clean, and fresh to render this unnecessary: 
I believe that the direction in which we are to work is toward securing 
the greatest attention to the care and feeding of cows and to the handling 
of milk in order to prevent every possible contamination ; and at the same 
time to have all cows whose milk is to be used for infant-feeding under 
close medical supervision. Until such a condition of things is realized, 
the heating of milk used for infant-feeding will be necessary. 



148 NUTRITION. 

Peptonized Milk. — Milk is peptonized through the agency of a sub- 
stance derived from the pancreas, usually of the pig. This is known in 
the market as " extractum pancreatis," the active ferment being the tryp- 
sine. As this acts only in an alkaline medium, bicarbonate of soda should 
first be added to the milk. The purpose of peptonizing is a partial or 
complete digestion of the casein of milk before feeding. 

Partially peptonized Milk. — This is done as follows : * One pint of 
fresh cow's milk and four ounces of water are put into a bottle, and a 
powder added containing five grains of extractum pancreatis and fifteen 
grains of bicarbonate of soda. This, is kept at a temperature of 105° to 
115° F. best by placing the bottle in water about as warm as the hand 
can bear comfortably. It should be shaken from time to time. For 
partial peptonization, the process is continued for from six to twenty 
minutes. The peptonizing powder is sold in glass tubes and in tab- 
lets. The tubes are to be preferred, as being less liable to deteriorate 
with age. Milk which has been peptonized ten minutes is not altered 
in taste; if, however, the process is continued for twenty minutes, a 
slightly bitter taste is noticed from the formation of peptone. This in- 
creases with the duration of the process of artificial digestion. If it is 
desired to arrest this after ten minutes, the milk may be raised to the 
boiling point, which destroys the ferment, or its activity may be stopped 
by placing the milk upon ice. If the milk is to be fed at once, neither 
of these procedures is necessary. If it is to be kept for several hours, 
scalding is more certain to arrest the change than lowering the tempera- 
ture. 

Completely peptonized Milk.- — The process is exactly the same as the 
above, except that it is continued for two hours, which is generally re- 
quired for the conversion of all the proteids into peptones. The addi- 
tion of acetic acid to such milk produces no coagulation. Although com- 
pletely peptonized milk is quite bitter, this is not an obstacle to its use 
for young infants, who after the first or second bottle do not usually 
object to its taste. For those who are a little older, the bitter taste may 
be covered by lemon-juice and sugar — one even teaspoonful of cane sugar 
and two teaspoonfuls of lemon-juice being added to each four ounces of 
the milk. 

Peptonized milk is to be diluted according to the age of the child. 
It is usually better to peptonize a milk-and-cream mixture which has 
previously been diluted with the proper amount of water. Peptonized 
milk is a valuable resource in chronic cases where there is feeble casein- 
digestion, and during attacks of acute indigestion in infancy. In acute 
attacks, completely peptonized milk is usually preferable to that which 
has been partially peptonized. It is not advisable to continue its use in- 

* Pairchild's process. 



CONDENSED MILK. 



149 



definitely ; if this is done the stomach gradually becomes less and less 
able to do this work. At most, peptonization should be used only for a 
month or two at a time, as the case improves being gradually diminished 
the amount of the powder used and the time of peptonizing. 

Condensed Milk. — This is prepared by heating fresh cow's milk to 
212° F. to destroy the bacteria and then evaporating in vacuo at a low 
temperature to a little less than one fourth its volume.* It is preserved 
in tin cans, usually with the addition of cane sugar in the proportion of 
about six ounces to a pint. The changes, therefore, to which the milk 
has been subjected are evaporation of a part of the water, partial or com- 
plete sterilization, and the addition of cane sugar. Fresh condensed milk 
to which no sugar had been added is delivered daily in New York and 
in other large cities. 

The composition of condensed milk is shown in the following table ; 
also the results obtained when it is diluted with six, twelve, and eighteen 
parts of water, as usually fed : 



Fat 

Proteids 

<, (Cane, 40-44 

Su S ar JMilk, 10-25 

Salts 

Water 



Condensed 
milk.t 



6-94 
8-43 

50-69 

1-39 
31-30 



With 6 parts 
of water 
added. 



0-99 
1-20 

7-23 

0-17 
90-49 



With 12 
parts of 
water. 



0-53 
0-65 

3-90 

0-10 

94-82 



With 18 
parts of 
water. 



Per cent. 

0-36 
0-44 

2-67 

0-07 
96-46 



The dilution with twelve parts of water is that most frequently em- 
ployed, although eighteen is often used for very young infants. 

The reasons both for the success and for the failure of condensed milk 
as an infant-food, are apparent from a study of its composition as it is 
ordinarily used. As a temporary food it is often useful, first, because it 
has been sterilized, and, secondly, because the casein of the cow's milk 
has been reduced by the usual dilution to such a point (about 0'6 per 
cent) that an infant with a very weak digestion can manage it, while it 
furnishes an abundance of sugar, the easiest thing for an infant to digest. 
During the first few months of life it is often apparently very successful 
for these reasons, but it can not be continued indefinitely without hazard. 
I have seen many infants reared exclusively upon it, but as yet not one 
who did not show, on careful examination, more or less evidence of rickets. 
Condensed milk fails as a permanent food, partly because it consists too 
largely of carbohydrates, but chiefly because it is lacking in fat. It is 



* Process followed by the Borden Condensed Milk Company. 

t Analysis made for the author by E. E. Smith, Ph. D., of Borden's Eagle-brand 
condensed milk. 



150 NUTRITION. 

admissible only for temporary use during attacks of indigestion, for very 
young infants during the first two or three months, or among the very 
poor, where the cow's milk which is available is still more objectionable. 
It should never be continued as a permanent food where good, fresh cow's 
milk can be obtained, nor should it be used as a permanent food without 
the addition of fat (cream). In travelling it is often the most convenient 
as well as the safest food to use. It should then be diluted twelve times 
for an infant under one month, and from six to ten times for those who 
are older. 

The fresh condensed milk has not the disadvantage of the addition of 
a large amount of cane sugar, and requires essentially the same modifi- 
cation as ordinary cow's milk. For the poor in cities it is often the best 
infant-food available. For routine use it should be diluted with from 
eight to twelve parts of water, with the addition of sugar — preferably 
milk sugar — and if possible fresh cream. 

Kumyss. — The original kumyss was fermented mare's milk, and has 
been extensively used by the Tartars for centuries both as a food and a 
beverage. In this country kumyss is made from cow's milk. The fer- 
ment used by the Tartars was kefir grains, consisting of two forms of the 
ordinary yeast plant and great numbers of lactic-acid bacilli.. The first 
kumyss made in the country was fermented by these grains, but they 
have now been discarded by most manufacturers of kumyss, as it is true 
that the bacteria which they contain are of no advantage and their effect 
may possibly be deleterious. Kumyss was formerly made chiefly from 
skimmed milk, but at present many manufacturers use the whole milk, 
with the addition of cane-sugar and a small proportion (about one six- 
teenth) of water. The process now most commonly employed is started 
with ordinary yeast, causing a vinous fermentation. This is carried on 
at a temperature of from 60° to 70° F. in corked bottles. At a little 
higher temperature the fermentation proceeds more rapidly, and may be 
completed in two or three days ; but better results are obtained with the 
slower process, which requires a week or ten days.* 

As thus manufactured, kumyss contains alcohol, carbon dioxide, lactic 
acid, and traces of butyric and acetic acids. The casein is first coagu- 
lated, and then broken up into minute particles by the agitation to which 
the kumyss is subjected during manufacture. Some of the casein is 
probably converted into album oses or similar compounds. 

Kumyss has an acid reaction and a peculiar taste somewhat resembling 



* The following is perhaps the best formula for the domestic manufacture of 
kumyss : One quart of fresh milk, half an ounce of sugar, two ounces of water, a piece 
of fresh yeast cake half an inch square ; put into wired bottles, keep at a temperature 
between 60° and 70° F. for one week, shaking five or six times a day, and then put 
upon ice. 



KUMYSS— MATZOON. 



151 



buttermilk ; at first often disagreeable, but a fondness for it is soon ac- 
quired by the majority of those who take it. Its composition is as 
follows : 





Made from 

mare's milk 

(Koenig). 


Made from 
cow's milk 
(Koenig). 


Made from 

skimmed milk 

(Koenig). 


Brush's kumyss 
(Doremus). 


Fat 


1-46 
2-24 
1-47 
1-91 
0-91 

6 : 42 
91-29 


1-83 
2-66 
4-09 
1-14 
0-55 

6 : 43 
89-30 


0-88 
2-89 
3-95 
1-38 
0-82 

6 : 53 
89-55 


1-91 


Proteids 

Sugar 


2-04 
3-26 


Alcohol 


0-62 






Acid 


0-30 


Carbon dioxide 

Salts 


0-44 
0-44 


Water 


90-99 







The advantages of kumyss are due to the alcohol, carbon dioxide, and 
lactic acid which it contains, and to the changes which have taken place 
in the casein of the milk by which its digestibility is very much facili- 
tated. It is more useful for older children than for young infants. It is 
a very valuable resource in many forms of acute and chronic indigestion. 
Kumyss is often retained when milk in any other form is vomited. In 
chronic cases it frequently stimulates the appetite and improves diges- 
tion. 

For infants, kumyss should be diluted, generally with an equal quantity 
of water. Many take it better if the gas has been allowed to escape by 
standing a few minutes. When the stomach is very irritable it should be 
given, preferably cold, in small quantities and frequently — e. g., a table- 
spoonful every twenty or thirty minutes. It is important to secure a reli- 
able article and one that is reasonably fresh. 

Matzoo2st. — Matzoon is a form of fermented milk first used in Asia 
Minor. The process of the manufacture of matzoon is given by Dadirrian 
as follows : Cow's milk is employed, with the addition only of an imported 
ferment which consists probably of a form of yeast. The milk is first 
boiled half an hour for sterilization. The fermentation is begun at a 
temperature of about 105° F. and continued in an open vessel for twelve 
hours, the temperature being gradually reduced to about 70° F., after 
which it is cooled, bottled, and kept on ice. It is ready for use in 
twenty-four hours. A very slow fermentation continues after bottling, 
so that the older matzoon is more sour than that freshly made ; older 
specimens contain also a little carbon dioxide. Matzoon keeps on ice 
for two or three weeks. It is a thick, curdy fluid with a taste some- 
what resembling sour cream. For infant-feeding it should be diluted 
with water and fed with a spoon, as it is too thick to be drawn from a 
bottle. 



152 NUTRITION. 

The composition of Dadirrian's matzoon is as follows : * 

Matzoon. 

Proteids 3-48 

Fat 3-49 

Milk sugar 3-68 

Lactic acid 0'90 

Alcohol and other products of fermentation 0*13 

Mineral salts • 69 

Water 87'63 

100-00 

By the process to which the milk is subjected there is, as in the manu- 
facture of kumyss, a decomposition of the milk-sugar into alcohol, lactic 
and carbonic acids. The changes in the proteids are quite similar to those 
in kumyss. In kumyss the fermentation goes on in the bottle, and conse- 
quently the carbonic acid is retained, while in matzoon the greater part 
of the gas escapes. The indications for the use of matzoon are the same 
as for kumyss. 

Junket, Curds and Whet. — Junket is made as follows : To one 
pint of fresh lukewarm cow's milk is added one teaspoonful of essence of 
pepsin or liquid rennet. It is stirred for a moment and then allowed to 
stand until firmly coagulated. It may be flavoured with wine, which 
should be added to it before coagulation, and given cold. The only 
change which has taken place is the coagulation of the casein, such as 
occurs in the stomach as the first step in digestion. Junket is useful in 
the feeding of older children, but should not be given to infants. 

Whet. — The milk is coagulated as above directed, the curd is then 
broken up with a fork, and the whey strained off through coarse muslin. 
To this whey may be added wine or brandy. From forty-six analyses 
Koenig gives the composition of whey as follows : 

Whey. 

Proteids 0'86 

Fat 0-32 

Sugar 4-79 

Salts 0-65 

Water 93-38 

100-00 

Whey is especially valuable for infants suffering from acute indiges- 
tion. It may be given in small amounts frequently, and will often be 
retained when everything else is vomited. It should be given cold. Wine 
whey is made by the addition of sherry wine, usually in the proportion of 
one part to sixteen. 

* Analysis of Leeds. 



BEEF PREPARATIONS. 



153 



BEEP PREPARATIONS. 

The nutrient properties of these preparations are to be measured by 
the amount of albumen they contain, their stimulant properties by the 
proportion of extractives. 

Beef Juice. — Expressed beef juice is made as follows : A piece of lean 
steak is slightly broiled, and the juice pressed out by a meat-press or a 
lemon-squeezer. Two or three ounces can ordinarily be obtained from 
one pound of steak. This is seasoned with salt and given cold or warm, 
but not heated sufficiently to coagulate the albumen in solution. 

Another excellent method of making beef juice without cooking, is 
by taking one pound of finely chopped lean beef and eight ounces of 
water and allowing this to stand in a covered jar upon ice from six to 
twelve hours. The juice is then squeezed out by twisting the meat in 
coarse muslin. It is seasoned with salt and given like the above. This 
is not quite so palatable as that obtained by the first method, because it 
contains a smaller proportion of extractives. It can be made so, how- 
ever, by the addition of sherry wine or celery salt. If the raw juice is 
added to milk in the proportion of two or three teaspoonfuls to each feed- 
ing, the taste will not be noticed. The milk should not be warmed above 
100° F. before the addition of the juice. 

The composition of the two products is shown in the following table : 

Beef Juice.* 





I. 

Expressed juice 
from 1 lb., warm 
process; quan- 
tity, 2% oz. 


II. 
Cold process, 
1 lb. beef, 8 oz. 
water ; quan- 
tity, 8X oz. 


Proteids 


2-90 
0-60 
3-40 
0-20 
92-90 


3-00 


Fat 




Extractives 


1-90 


Salts 


0-20 


Water 


94-90 








100-00 


100-00 



The only difference in the two preparations is that the first contains 
about twice as much of the extractives. The second process is much more 
economical, as more than three times as much juice can be obtained from 
a given quantity of beef. If a stronger juice is desired, the amount of 
proteids may be doubled by using only four ounces of water. This is 
preferable for all except young infants. 

Beef extracts are not to be considered in any sense as foods. Kem- 
merich has shown that animals receiving nothing else died of starvation, 



* Analysis made for the author by E. E. Smith, Ph. D. 



154 NUTRITION. 

and even sooner than when everything was withheld. According to Chit- 
tenden, they contain no nitrogen in the form of proteids, but only in com- 
bination with the soluble extractives. They are stimulants, and as such 
are often useful. 

Of the other preparations of beef in the market probably the best are 
Mosquera's beef jelly, bovinine, the beef peptonoids of the Arlington 
Company, and Murdock's liquid food. These contain from ten to thirty- 
five per cent of proteids available for nutrition. They are valuable addi- 
tions to milk in the artificial feeding of infants. They also furnish a 
proteid which can be used in many cases of indigestion where milk is not 
admissible. For infants they must be well diluted. They are valuable 
in older children in many cases of general malnutrition. 

Raw scraped beef, or that which has been slightly cooked, is easily 
digested by most young children. There are many conditions in which 
other forms of proteid, particularly casein, are not well borne, and indeed 
can not be taken at all, where children even as young as twelve months 
appear to digest this beef-pulp without any difficulty. It should be made 
from very rare or raw steak, finely scraped and well salted. A table- 
spoonful may be given at one feeding to a child of eighteen months. In 
nutrient properties this far exceeds most of the beef preparations in the 
market. The alleged danger of tapeworm from the use of raw meat, is 
in this country so slight that it may be disregarded. 

Broths. — Animal broths may be made from mutton, veal, chicken, or 
beef. A good formula for general use is the following : One pound of 
lean meat, one pint of water ; stand for four or five hours, then cook over 
a slow fire for one hour down to half a pint. After it has cooled, skim 
off: the fat and strain through a cloth. The composition of a broth so 
made is given by Cheadle as follows : 

Beef Broth. 

Proteids 1 • 02 

Extractives 1'82 

Fat 

Salts 0-88 

Water 96*28 

100-00 

From its composition it will be seen that broths are not very nutri- 
tious ; they are, however, quite stimulating, and are at times useful, par- 
ticularly where milk is to be temporarily withheld; but they are not 
adapted to prolonged use. Broths which have been thickened with either 
barley or rice flour are useful for children in the second and third years. 

CEREALS. 

Barley Water. — This is to be made either from the grains or from the 
barley flour. When the grains are used, the following is the formula 



INFANT-FOODS. 155 

which I have been accustomed to employ : To two tablespoonfuls of barley, 
add one quart of water, and boil continuously for six hours, keeping the 
quantity up to the quart by the addition of water ; strain through coarse 
muslin. It is an advantage to soak the barley for a few hours, or even 
over-night, before using. The water in which it is soaked is not used. 
When cold this makes a rather thin barley jelly. Its composition by 
analysis is as follows : 

Barley Water. 

Starch 1-63 

Fat 0-05 

Proteids 0-09 

Inorganic salts • 03 

Water 98*20 

100-00 

Almost an identical product may be obtained by using either the pre- 
pared barley flour of the Health Food Company, New York, or Eobin- 
son's barley, two drachms — one even tablespoonf ul — to each twelve ounces 
of water, and cooking for fifteen minutes. This is certainly a simpler 
and easier method of preparation. 

Rice Water, Oatmeal Water, etc. — These may be made in the same 
manner as the barley water, using the same proportions either of the 
flour or the grains. Salt should always be added to these gruels if used 
alone. These substances are useful, being a convenient form in which 
starch may first be added to the food of infants when old enough to 
digest it, i. e., about the eighth or ninth month. They may also be used, 
when more dilute, to allay thirst when the stomach is irritable, and when 
milk in all forms must be temporarily withheld. Kice water and barley 
water are usually preferable in cases of diarrhoea, and oatmeal water 
where there is a tendency to constipation. 

INFANT-FOODS. 

It is not possible, nor even desirable, for a physician to know all about 
the infant-foods with which the market is flooded. He should, however, 
at least know that they are not perfect substitutes for breast-milk, that as 
permanent foods they are greatly inferior to properly modified cow's milk, 
and that as often used by the laity, and even by the medical profession, 
they are capable of doing and have done much positive harm. There are 
two diseases — rickets and scurvy — which have so frequently followed their 
prolonged use, that there can be no escaping the conclusion that they were 
the active cause. This is the unanimous verdict of all physicians whose 
experience entitles them to speak with authority upon the subject of 
infant-feeding. On the other hand, there are times when some of these 
preparations may be of considerable value, but chiefly for temporary use 
in pathological conditions. Here they are to be prescribed like drugs, 



156 



NUTRITION. 



but only with a very definite knowledge of exactly what they do and what 
they do not contain. The most commonly used infant-foods may be 
grouped as follows : 

1. The Milk Foods. — Nestle's food is perhaps the most widely known. 
The others closely resembling it in composition are the Anglo-Swiss, the 
Franco-Swiss, the American-Swiss, and Gerber's food. These foods are 
essentially, sweetened condensed milk evaporated to dryness, with the 
addition of some form of flour which has been partly dextrinized ; they 
all contain a large proportion of unchanged starch. 

2. The Liebig or Malted Foods. — Mellin's food may be taken as a type 
of the class. Others which resemble it more or less closely are Liebig's, 
Horlick's food, Hawley's food, and malted milk. Mellin's food consists 
principally (80 per cent) of sugar. This is derived from malted wheat 
and barley flour, and is composed of a mixture of dextrines, dextrose, and 
maltose, with a small amount of cane sugar. 

3. The Farinaceous Foods. — These are imperial granum, Ridge's food, 
Hubbell's prepared wheat, and Robinson's patent barley. The first con- 
sists of wheat flour previously prepared by baking, by which a small pro- 
portion of the starch — from one to six per cent — has been converted into 
sugar. In chemical composition these four foods are very similar to each 
other, consisting mainly of unchanged starch which forms from seventy- 
five to eighty per cent of their solid constituents. 

4. Miscellaneous Foods. — Under this head may be mentioned (1) Carn- 
rick's soluble food, which is composed mainly of carbohydrates, more 
than one half being unchanged starch, the fat being chiefly cocoa butter ; 
(2) lacto-preparata, which differs from the above chiefly in the fact that 
the starch has been replaced by milk sugar ; (3) lactated food, which is 
composed of about seventy-five per cent carbohydrates, nearly one half of 
which is unchanged starch. 

The Composition of Infant-Foods.* 



Fat 

Proteids 

Dextrines 

Dextrose and maltose. 

Cane sugar 

Milk sugar 

Total soluble carbo- 
hydrates 

Insoluble carbohy- 
drates (starch) 

Inorganic salts 

Moisture 



Per cent. 

5-48 
11 04 



30-59 
7-60 



45-57 

29 95 
1-72 
1-50 



Per cent. 

0-31 
10-70 
40 96 
37-38 
423 



82' 51 



3-20 
4 



Per cent. 
266 
1518 
31-97t 
3179 
4-15 



67 91 



334 

2-20 



Ridge's food. 



Per cent. 
I'll 
11-93 
1-23 
0-52 
1-16 



77-96 
0-49 
8-58 



Imperial 
granum. 



Per cent. 

1-04 
14 13 
1-38 
0-42 
Trace. 



7611 
039 
8-38 



Lacto-preps- 
rata. 



Per cent 
12- 
14: 



63-68 



63- 



5-80 



Carnrick's 
soluble food. 



27 



* With the exception of lacto-preparata and Carnrick's soluble food, which are taken from 
Leeds, all these analyses were made for the author by E. E. Smith, Ph. D. In general they corre- 
spond with those previously published by Leeds, Rach, Trimble, Stutzer, and others. 

t Including milk sugar. 



PLATE III. 



WOMAN'S MILK. 



COW'S MILK. 



Proteids. 

Fat. 

Soluble Carbohydrates (sugar). 

Salts. 

Insoluble Carbohydrates (starch) 



CONDENSED MILK, (diluted six times.) 



MELLIN'S FOOD- 



MALTED MILK. 



NESTLE'S FOOD. 



CARNRICK'S SOLUBLE FOOD. 



IMPERIAL GRANUM. 



Chart showing composition of various infant foods compared with woman's milk. 



INFANT-FEEDING. 



157 



A better idea can be obtained of these foods by the study of the fol- 
lowing table, where they are diluted with water for comparison with milk : 

Infant-Foods diluted with Water to compare with Milk. 



Fat , 

Proteids 

Soluble carbohydrates (sugars) . . 
Insoluble carbohydrates (starch). 

Inorganic salts 

Water 







Condens. 












Breast 


Cow's 


milk, 


Mellin's 


Malted 


Nestle's 


Ridge's 


Imperial 


milk. 


milk. 


diluted 
6 times. 


food. 


milk. 


food. 


food. 


granum. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


4-00 


350 


099 


004 


039 


076 


0-16 


014 


150 


400 


1-20 


150 


2-28 


1 54 


1 67 


198 


700 


430 


723 


11-56 


10 18 


6 38 
419 


041 
10 91 


025 
1065 


6-20 


6-70 


017 


0-45 


0-50 


024 


07 


006 


87-30 


87 -50 


90 41 


86-45 


86 65 


86-89 


86-78 


8692 



Carn- 
rick'i 

soluble 
food. 

Per cent. 

ria 

135 
406 
561 
56 
7 30 



The accompanying graphic chart (Plate III) shows in another form 
the same thing as the last table. In it are seen at a glance the essential 
features in the composition of most of the foods, viz., the large propor- 
tion of carbohydrates and the absence of fat. As a class then, infant-foods 
contain an excess of carbohydrates, and many of them a large percentage 
of unchanged starch. The proteids, though often sufficient in amount, are 
chiefly vegetable, and not animal proteids. Without exception they are 
lacking in fat, and therefore they do not furnish all that the growing 
organism requires. They should not be used except in those forms of 
indigestion where we desire temporarily to withhold fat and casein and to 
employ as food only carbohydrates. They can not be used as exclusive 
foods for any considerable period without disastrous results. Their con- 
tinued use without some addition of fresh milk should never in any cir- 
cumstances be countenanced. While some of them may furnish the addi- 
tional carbohydrates required by an infant who is fed upon diluted cow's 
milk, they can not do more. The group of farinaceous foods, as they fur- 
nish starch in a convenient and palatable form, may often be ad van; 
ously used as an addition to milk after the ninth month and during the 
second year. 



CHAPTER III. 
IN FA NT-FE E DING. 

The different methods of feeding which are available are: 

1. Breast-feeding, either by tin- mother or by a wet-nui 

2. Mixed feeding, or a combination of nursing and artificial feeding. 

3. Artificial feeding exclusively. 

In deciding which one of these methods shall be used, all the condi- 
tions, such as the health of the mother, the vigour of the child, and its 
surroundings, must be taken into consideration. The first choice should 



158 NUTRITION. 

always be maternal nursing. If it is not possible for the mother to nurse 
her infant entirely, nursing may be supplemented by feeding either from 
the outset or after the third or fourth month. If the conditions are such 
that maternal nursing is impossible or impracticable, the question to be 
decided is one of 

Artificial Feeding vs. Wet-nursing. — Neither method of feeding is to 
be used exclusively. While recent advances made in artificial feeding 
have greatly diminished the necessity for wet-nurses, there are still many 
instances where, objectionable though they may be, they are indispensable 
for saving the life of the child, as the perfect substitute for good breast 
milk is as yet undiscovered. 

If artificial feeding can be begun at birth and carried on according to 
the most approved methods, it is highly successful in the great majority 
of cases in which maternal nursing is impossible. In my experience, fully 
ninety per cent of the infants seen in private practice can with care be 
so reared. The remainder of the cases will require wet-nurses ; these in- 
cluding chiefly infants who are prematurely born or those who are deli- 
cate from birth, and those with especially weak digestion, who are reared 
only with the greatest difficulty under any circumstances. This state- 
ment applies particularly to infants living in large cities. If, however, 
artificial feeding has been badly begun, and so carried on for two or three 
months that, when the child comes under observation, a condition of 
chronic indigestion is established, the difficulties in the way of artificial 
feeding are much increased, and the proportion of cases in which wet- 
nurses are required will be much larger. Whether or not a wet-nurse 
shall be employed at this juncture will depend upon the circumstances 
surrounding each case. If the child has steadily lost flesh so that it 
weighs only a little more than at birth, if it lives in a large city, or if the 
season is midsummer, the necessity for a wet-nurse is very much increased. 
In these circumstances, the great danger is the supervention of some acute 
disease of the stomach or intestines, to which a child in this condition 
is very liable, and which it may not be able to survive. Unless such a 
child begins very soon to improve with proper methods of artificial feeding, 
a wet-nurse should be secured. If the child lives in the country, if the 
weather is cool, and if the child is holding its own in weight, a faithful 
trial of proper feeding should be made before resorting to a wet-nurse. 
If the child, at the time of coming under observation, is suffering from an 
attack of acute indigestion, or from the symptoms of acute inanition, a 
wet-nurse should be obtained at once. I believe that the day will soon 
come when no physician will lay before his patient the choice of a wet- 
nurse or artificial feeding in the case of a healthy infant whose mother can 
not or will not nurse it ; but that the general attitude of the profession 
will be, artificial feeding if possible, wet-nursing only if necessary. I am 
well aware that this practice is not followed by many of the leading 



ARTIFICIAL FEEDING VERSUS WET-NURSING. 159 

physicians in New York, who still adhere to the practice of employing 
wet-nurses in every instance in which maternal nursing is impossible. 
This is largely due to a want of familiarity with the methods and results 
of the best artificial feeding, while the results of improper artificial feed- 
ing are to be seen on every hand. 

The disadvantages in the employment of wet-nurses are many, and 
almost as difficult to overcome as those attending artificial feeding. In 
the first place, good ones are difficult to obtain, and outside of a large 
city it is almost impossible to obtain one of any kind. While it is true 
that good breast milk is unquestionably the best infant-food, it is equally 
true that properly modified cow's milk is a far better food than the milk 
of many wet-nurses who are employed. The expense of wet-nurses — 
twenty to thirty-five dollars a month in New York — places them out 
of the reach of many who need them most; and, finally, the class of 
women from which most of our wet-nurses are drawn, are very undesirable 
inmates of a household, and are often the source of endless trouble and 
annoyance — a nuisance which must be tolerated for the sake of the baby. 
The danger of the transmission of disease from the nurse to the child is 
a real one. Numerous instances are on record of syphilis being communi- 
cated in this way, and some have come under my own observation. It is 
possible that tuberculosis may be transmitted through the milk, although, 
like syphilis, this is much more liable to result from other contact with 
the nurse, especially kissing. 

The moral question involved in the subject of wet-nursing is one 
which neither the physician nor the family who employ the nurse can 
ignore, for it is no small thing to deprive an infant of its mother's breast 
when, as statistics show to be true of the children of wet-nurses, this fact 
reduces its chance of survival to one in ten. The family should be com- 
pelled by the physician to consider this aspect of the question, and to see 
to it that proper provision for the care of the wet-nurse's child is made, so 
as to give it the best possible chance with artificial feeding. If the wet- 
nurse's child is two months old, its chances of getting on without the 
mother are vastly improved, while her usefulness as a wet-nurse is not 
thereby diminished. It should therefore be required that, whenever cir- 
cumstances permit, every woman who goes out as a wet-nurse should 
nurse her own infant for at least two months before she leaves it. 

The unnecessary employment of wet-nurses is no doubt an evil, and 
has a bad influence upon those who make wet-nursing a business, as 
many women in cities are tempted to do on account of the large wages 
which they are able to earn for very easy work. If a wet-nurse were 
retained in her place only as long as the needs of the child required — 
i. e., until it had arrived at a sufficient age, and its digestion had suffi- 
ciently improved to enable it to thrive upon modified cow's milk — she 
could be dispensed with in a month or two months, and could then 



160 



NUTRITION. 



seek another place. In this way a small number of nurses could be 
made to do duty for quite a large number of children. This is practi- 
cally just what is done in several of our large institutions, where a deli- 
cate child is wet-nursed only long enough to give it a start, which may 
require two weeks, one month, or three months, as the case may be. And 
just in this way should wet-nurses be used in private practice, as furnish- 
ing an infant-food easy of digestion, and one without which sometimes we 

can not get along. 

BREAST-FEEDING. 

I. Maternal Nursing.— Maternal nursing is desirable whenever it is 
possible. Under the following conditions, however, it should not be at- 
tempted : 

(1) No mother who is the subject of tuberculosis in any form, whether 
latent or active, should nurse her infant ; it can only hasten the progress 
of the disease in herself, while at the same time it exposes the infant to 
the danger of infection. (2) Nursing should not be allowed where serious 
complications have been connected with parturition, such as severe 
haemorrhage, puerperal convulsions, nephritis, or puerperal septicaemia. 
(3) If the mother is choreic or epileptic. (4) If the mother is very deli- 
cate, since great harm may be done to her, without any corresponding 
benefit to the child. (5) Where experience on two or three previous occa- 
sions under favourable conditions has shown her inability to nurse her 
child. (6) When no milk is secreted. With reference to the fourth and 
fifth conditions an absolute opinion can not always be given at the outset. 
In cases of doubt, nursing may be allowed tentatively, the effect upon both 
mother and child being carefully watched. In view of the great value of 
maternal nursing to the child, the physician should encourage it and use 
every means in his power to make it easy. 

Care of the Breasts during Lactation. — For the safety of both mother 
and child it is essential that the most scrupulous attention be given to 
cleanliness. The nipples, and the breasts as well, should always be care- 
fully washed after each nursing. Usually plain water is sufficient, or a 
weak boric-acid solution may be employed. 

Nursing during the First Days of Life. —This is necessary, to accustom 
the child and the mother to the procedure, to promote uterine contrac- 
tion, and to empty the breasts of the colostrum. All these results can 
be attained by putting the child to the breast on the first day once in six 
hours, on the second day once in four hours. It is unnecessary to repeat 
the process more frequently. The child gets from the breast only from 
four to six ounces a day during the first two days. Did it require more 
nourishment before the milk-flow is usually established, we may be sure 
that Nature would not have been so late with her supply. Considering 
how great are the changes taking place during these first days in the circu- 
latory and respiratory systems, we are hardly surprised that two days pass 



BREAST-FEEDING. IgX 

before the organs of digestion are given much work to do. The common 
practice of administering to an infant a few hours old all sorts of de- 
coctions, with the idea that because it cries it is suffering from colic, can 
not be too strongly condemned. A certain amount of crying is proper and 
necessary. In exceptional circumstances, when an infant is unusually 
strong and robust and screams excessively, and especially when the tem- 
perature is elevated (see page 121), it may be necessary to give food before 
the third day ; but this is not to be the rule. A little warm water, or a 
five-per-cent solution of milk sugar, should first be given ; from two to 
four teaspoonfuls at a time are sufficient. This often satisfies the child ; 
when it does not do so, regular feeding should be begun on the second 
day. Should the milk be delayed beyond the second day, feeding should 
then be begun at regular intervals, as in the cases which are to have no 
breast-milk. 

Nursing Habits. — Good habits of nursing and sleep are almost as easily 
formed as bad ones, provided one begins at the outset. A vast deal of the 
wear and tear incident to the nursing period may be avoided if the child 
is trained to regular habits. Attention to these minor points often makes 
all the difference between successful and unsuccessful nursing. They 
should not be thought beneath the physician's notice, nor relegated en- 
tirely to the nurse. The physician must have a very clear notion of how 
often nursing is necessary, must give very explicit directions, and see that 
they are carried out. After the third day, for the first month, ten nurs- 
ings in the twenty-four hours are quite sufficient, and no more should be 
allowed. .An infant at this age can usually be depended upon to take at 
least one long nap of from four to five hours in the course of the twenty- 
four. For the rest of the day the child may be awakened, if necessary, 
at the regular nursing time, and put to the breast ; this plan being con- 
tinued until nine o'clock at night. It should then be allowed to sleep as 
long as it will, and but two nursings given between this hour and seven 
in the morning. In the course of two or three weeks a healthy infant 
can usually be trained to nurse and sleep with almost perfect regularity, 
frequently, when a month old, going six hours regularly at night without 
feeding. A trained nurse of my acquaintance states that out of thirty- 
three infants of which she had the care from birth, thirty-one were trained 
without difficulty in the manner described. In only one case was the 
training a failure — that of a delicate, highly nervous child. Of course, 
success in training must rest almost entirely with the nurse ; but the 
physician should at least appreciate its importance and lend it his sup- 
port. The great gain to the mother is, that she is enabled to have a 
quiet, undisturbed night. This is of the utmost importance, and has more 
to do with a good milk supply than any other single thing in connection 
with the mother's habits. So far as the child is concerned, regular habits 
of feeding and sleep, and regular evacuations from the bowels, which 
U 



162 



NUTRITION. 



nearly always go with them, are important factors in infant hygiene, 
especially in the prevention of gastro-enteric diseases. 

Schedule for Breast-Feeding. 



Age. 



First day 

Second day 

Third to twenty-eighth day 
Fourth to thirteenth week. . 

Third to fifth month 

Fifth to twelfth month 



Number of nurs- 
ings in 24 hours. 



Interval during 
the day. 



Hours. 
6 
4 
2 
8* 
3 
3 



Night nursings 

between 9 p. m. 

and 7 a. m. 



These rules can be carried into effect with but little difficulty, and 
with great benefit to both mother and child. It is to be remembered that 
we are here speaking only of healthy children. The possibility of train- 
ing children to eat and sleep in the manner described will be doubted only 
by one who has not made a careful trial of it. Eelieving the mother of 
night-nursing after the child is five months old is of the greatest value, 
and will often enable her to go on with lactation, when otherwise it would 
be brought to an abrupt termination. On no account should the child 
be allowed to sleep upon the mother's breast, nor in the same bed with 
the mother. The temptation to frequent nursing is in this way in great 
measure removed. No mere sentiment in regard to these matters should 
be allowed to interfere with the plain dictates of reason and experience. 

Symptoms of Inadequate Nursing. — So frequently does it happen that 
a mother is anxious to nurse her child, and after two or three months it is 
discovered that lactation is a failure and artificial feeding must be re- 
sorted to, that it is important that the question of ability to nurse should 
be settled as early as possible. The lives of children are often jeopard- 
ized by the vain efforts of a conscientious mother to do what she is phys- 
ically unable to do. The physician should be familiar with the symptoms 
of inadequate nursing, in order that valuable time may not be wasted. If 
artificial feeding is to be employed, the difficulties are much less when it 
is begun early than after the digestion has been deranged by several weeks 
of very poor nursing. 

1. During the first four or five days of life the most important sign of 
insufficient food is the temperature. As a rule, a child who gets a proper 
amount from the breasts has a normal temperature. Very many who get 
little or nothing during this time have a temperature of 101° or 102° F., 
and, in extreme cases, 104° or even 106° F. If no obvious symptoms of 
illness are present, such a temperature from the second to the fifth day 
may be looked upon as indicating insufficient nourishment, or even starva- 
tion. (See page 118.) 



BREAST-FEEDING. 163 

2. There is no gain in weight. All infants, and particularly those 
whose nutrition is the subject of special difficulty, should be weighed 
twice a week during the first six months. No matter what other symp- 
toms are present, the scales are an unerring guide by which we are to 
judge the results. A child need not gain rapidly, but should always gain 
steadily unless obvious signs of disease are present. One should not be 
satisfied unless the weekly gain is at least four ounces. In the great ma- 
jority of cases a failure to gain in weight during the first six months, 
depends upon the nourishment, and upon that alone. 

3. The sleep is irregular and disturbed. A healthy infant, after its 
appetite has been satisfied, usually goes to sleep at once and sleeps quietly 
for two or three hours ; or, if awake, it lies in placid contentment, ex- 
hibiting all the signs of physical well-being. If, after being nursed, a 
child wakes habitually fifteen or twenty minutes after being put down, 
and rarely has a long sleep except from exhaustion, the probabilities are 
great that the food is insufficient in quantity or very poor in quality. 

4. There is frequent fretfulness or crying. This may, of course, be 
due to many causes in infancy, but by all odds the most common one is 
lack of proper food or the indigestion which this produces. 

5. The stools are irregular and of an unhealthy appearance. There 
may be constipation with dry, hard stools, or frequent green fluid stools, 
from four to twelve a day, often containing undigested food, and after a 
time mucus. 

G. The child nurses a long time before it is satisfied. Usually the 
greater the milk supply, the shorter the time required to satisfy the child's 
appetite. Where the milk is abundant, five or six minutes are often suffi- 
cient. If the milk is very scanty, an infant will frequently nurse half 
or three quarters of an hour and then stop, more because it is tired out 
than because it is satisfied. If this is habitual, it is almost certain that 
the milk is very scanty. Sometimes a scanty supply is indicated by ex- 
actly the opposite symptom, viz., the child seizing the breast and nursing 
vigorously for a few moments, then dropping the nipple in apparent dis- 
gust and refusing to make any further efforts. This symptom is often 
seen where the breasts are practically empty. 

7. The symptoms during the later months are stationary weight or a 
gradual loss, soft, flabby muscles, inability to sit alone or to stand at the 
proper age, delayed closure of the fontanel, delayed dentition, and fre- 
quently perspiration about the head. In addition, there are the general 
signs of malnutrition, anaemia, fretfulness, and irregular bowels, or there 
may be added the symptoms of incipient rickets. 

The above symptoms are sufficiently characteristic to enable one to be 
quite sure of the fact that the child is not thriving. The proper course 
now is to examine the milk and see in what respect it is abnormal : whether 
it is simply the quantity that is at fault, or the quality, or both. While 



164 



NUTRITION. 



such an examination does not always solve the problem, it is of very great 
assistance and in the majority of cases two or three examinations of the 
milk, in connection with the other symptoms, will enable the physician 
to decide the question and apply the appropriate treatment. 

The Management of Woman's Milk where Nursing Infants are not 

Thriving. The milk examination usually discloses one of four conditions : 

(1) an over-rich milk, quantity usually abundant; (2) milk poor in qual- 
ity and scanty ; (3) quality good, amount scanty ; (4) quantity abundant, 
quality poor. 

Excessively rich milk.— This is usually found under the following 
conditions: The woman is in good health, has large, well-developed 
breasts, which are full and tense at nursing time. In most cases she is 
upon a very abundant diet, largely of nitrogenous food, getting little or 
no exercise, and frequently taking alcohol with the notion that because 
the child is not thriving the milk is poor. This is often seen in the 
wet-nurse after making a change from the simple life and habits of home 
to the more luxurious life and diet of the family to which she goes. The 
following analyses from Botch are a good illustration of the exact com- 
position of milk under such circumstances : Analysis I shows milk of a 
healthy but under-fed wet-nurse two days before change of food ; II, the 
milk of the same nurse after one month of rich food with very little exer- 
cise ; III, milk of the same nurse, the food and exercise being regulated : 





I. 


n. 


III. 


Fat 


Per cent. 

0-72 
2-53 
6-75 
0-22 


Per cent. 

5-44 
4-61 
6-25 
0-20 


Per cent. 

5-50 


Proteids 


2-90 


Sugar 


6-60 


Salts] 


0-14 







The effect of the diet and life is seen to be high fat and high pro- 
teids. As a result of the exercise, there is seen a very marked reduction 
in the proteids. The clinical examination shows the cream to be from 
eight to twelve per cent, and the specific gravity from 1,032 to 1,033. 
Instead of weaning the baby, or dismissing the wet-nurse because the 
child has indigestion or loses in weight, certain changes should be insti- 
tuted. Alcohol should be entirely prohibited. The diet, especially the 
meat, should bo reduced, and the nurse required to take daily exercise in 
the open air, particularly by walking. The improvement following such 
a regimen is often immediate, the child's symptoms disappearing in the 
course of ;i few days and a regular gain in weight beginning. 

Scanty milk of a poor quality. — This is most often seen in a delicate 
or anamic mother — one, perhaps, who has had a difficult or complicated 
labour, who is emotional, anxious, and careworn. In such cases it is often 
with the greatest difficulty that we can secure the necessary half ounce 



BREAST-FEEDING. 165 

required for examination. The milk is sometimes so poor that we can 
decide positively after two examinations that it is useless to continue 
lactation. In such cases we often find the specific gravity from 1,024 to 
1,027, and the cream only two or three per cent. In other cases, where 
the variations from the normal are not so great — i. e., specific gravity 1,030, 
cream four per cent, and the quantity fairly abundant — we may be able so 
to improve the milk that lactation may be easily and advantageously con- 
tinued. In the management of such cases the first thing is to secure to 
the nurse undisturbed rest at night. If possible, she should be entirely 
relieved of the care of the infant at this time, and if feeding is necessary 
the bottle should be given. She should have a certain amount of fresh 
air every day, driving if possible, or walking as soon as she is able to take 
more active exercise. One of the most powerful stimulants to the secre- 
tion of milk is massage of the breasts. A. M. Thomas (New York) places 
it above all others. It should be done with great care and gentleness, but 
most of all with every precaution against infection. The entire breast, 
including the nipple, should be rendered aseptic, as should the hands of 
the masseuse. Some mild antiseptic ointment may be used with the 
massage. It should be done two or three times a day for ten minutes. 
The diet should be abundant, with a large allowance of milk and meat, 
especially beef. If there is anaemia, iron should be given. Some of the 
alcoholic extracts of malt are useful. Every means should be taken to 
improve the general nutrition, for whatever benefits this improves the 
milk. If the conditions present are incident to the confinement or the 
convalescence, the prognosis is good ; and in the course of a week or two 
very marked improvement may be evident, and lactation may be success- 
fully continued. If, however, the conditions depend upon constitutional 
debility, or if the person has an exceedingly nervous temperament, the 
prognosis is much worse. Temporary improvement may take place, but it 
soon becomes evident that the experiment is a failure, both as regards 
mother and child. 

Quantity deficient, quality normal. — This is often apparently the case, 
but really it is rarely so. If, in taking the specimen for examination, the 
child is first allowed to nurse for one or two minutes as has been suggested, 
there may be left only the final portion, or " strippings," which part is 
always much richer in fat than the whole milk. An examination of such 
a specimen often gives an excellent showing when the milk is really poor. 
In all cases of scanty supply, the entire quantity from the breasts should 
be secured for examination. If the only object in treatment is to increase 
the quantity, this can usually be accomplished by largely increasing the 
fluids, especially milk, and by taking alcoholic malt extracts. 

Quantity abundant, quality very poor.— This condition is usually seen 
in women who, to improve the milk, have been taking large quantities of 
fluids, often with alcohol in some form. In such cases, instead of being a 



166 NUTRITION. 

formation from the epithelium of the glands, the milk is chiefly a transu- 
dation from the blood-vessels. Where the patient is very anaemic and the 
general condition poor, the glands act as little more than a filter. In 
such circumstances the breasts may be so full as to be painful, and the 
milk may often come away spontaneously. An examination usually shows 
low specific gravity and very low fat. Where these conditions exist nurs- 
ing should be discontinued. 

Summary. — Excessively rich milk is in most cases easily modified by 
a reduction in the diet and increase in exercise. Poor milk is usually low 
in fat and scanty in quantity, while the proteids may be either high or 
low. If the variations from the normal are only moderate, and the causes 
are such as can readily be removed, the prognosis is good. If the opposite 
condition exists, the prognosis is bad, and the chances of permanent im- 
provement are slight. On the whole, artificial feeding gives so much 
better results than poor or doubtful nursing, that I am inclined, as a 
result of increased experience, to. stop nursing and begin artificial feeding 
early, rather than waste time in prolonged efforts to improve the breast- 
milk. Nursing that is continued only by high pressure, by stimulants, 
and by deluging the mother with fluids, is rarely advantageous either for 
mother or child. 

II. Wet-Nursing. — In the selection of a wet-nurse, it is by no means 
so essential as has generally been supposed, that her child shall be of 
about the same age as the child she is to nurse, for, after the first 
month, the changes in the composition of breast milk are insignificant. 
It is always desirable that the wet-nurse shall have nursed her own infant 
long enough to demonstrate the fact that she has an abundance of good 
milk ; hence, taking a wet-nurse at the end of the first or second week is 
always fraught with considerable uncertainty. For an infant six weeks 
old, a wet-nurse whose milk is anywhere between one and five months old 
will usually answer perfectly well. For an infant only two or three weeks 
old, the milk should not be more than six weeks old. 

A good nurse must, first of all, be a healthy woman, free from syphi- 
litic or tubercular taint, and her throat, teeth, skin, glands, hair, and legs 
should be carefully inspected. She must have a good glandular develop- 
ment. Not much is to be expected of small flat breasts. The breasts 
must be full and hard three hours after nursing. They may be very 
large and yet supply very little milk, being composed almost entirely 
of fat. On the other hand, some smaller breasts may be almost all glan- 
dular tissue. The difference in the size of a breast before and after 
nursing, is one of the best guides to the amount of milk it is secreting. 
The nipples should be free from erosions or fissures, and long enough for 
the needs of the child. The nurse should not be anaemic, since it is im- 
possible for a pale, anaemic woman to furnish good milk. Preferably she 
should be of a phlegmatic temperament, and of a good moral character. 1 



WEANING. 107 

This is desirable for personal reasons, although there is no evidence of 
moral qualities being transmitted through the milk. It is desirable that 
a nurse should be between twenty and thirty years of age, although much 
more depends upon the individual than upon the age. Other things being 
equal, a primipara should be chosen. The best evidence to be obtained 
of the character of a woman's milk is the condition of her own child ; 
hence, if possible, it should be examined before she is accepted. It often 
happens that a woman who has had an abundant supply of milk for her 
own infant, has very little for. another infant for the first few days in her 
new surroundings. This is usually the result of the nervous influences 
connected with parting from her own child, going to a new place, being 
carefully watched, etc. In such a case it should not be too readily de- 
cided that she is incompetent as a nurse, for, under most circumstances, 
with proper treatment her normal flow of milk will be re-established. 

III. Weaxixg. — Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and child. Sudden weaning is apt 
to be followed by an attack of acute indigestion. This, however, is not 
an invariable result, and usually depends upon the fact that the child is 
given cow's milk with insufficient dilution. Weaning in hot weather is 
usually to be avoided, but the harm from this is not nearly so great as 
sometimes results where lactation is unduly prolonged because of a preju- 
dice against a change of food at this time. While there are many 
women of the lower classes who are able to nurse their children to advan- 
tage for the entire first year, the number of such among the better classes 
is certainly very small. By the latter, nursing can rarely be continued 
beyond the ninth, and often not beyond the sixth month, without unduly 
draining the vitality of the mother and at the same time harming the 
child. The late months of lactation, like the early months, require close 
watching. It is a common mistake to continue both maternal and wet- 
nursing too long, owing to a dislike of making a change when things are 
going tolerably. It is a safe rule to make the ninth month the time to 
supplement the breast-feeding by other food. But here, as in the early 
months, the child's weight is the safest guide. In the absence of evident 
signs of disease, a stationary weight for several weeks makes weaning 
advisable ; a steady loss makes it imperative. 

The accompanying weight-chart from a private patient (see Fig. 30) 
illustrates this point. The infant was nursed by the mother, and did un- 
usually well until the sixth month. As it did not seem ill, the parents 
were not disturbed by the gradual loss in weight, and I was not consulted 
until the loss had reached three pounds. Feeding was at once begun, and 
in a week all nursing was stopped and the child gradually regained its lost 
weight. It was subsequently discovered that the mother was pregnant at 
the time the loss was going on. 

When a nursing infant has been accustomed from birth to take either 



168 



NUTRITION. 



milk or simply water from a bottle once a day, as is the practice of many 
physicians to order, gradual weaning is generally an easy matter. Other- 
wise it is sometimes an impossibility, the child refusing all food except 
the breast so long as this is given, and nothing but starvation inducing 
it to take food either from a bottle or a spoon. Infants will sometimes 
refuse food until so weak as to make their condition serious. 

Sudden weaning may be required at any time from the development 
in the mother of acute disease of a serious nature, such as typhoid fever 
or pneumonia, grave chronic disease, such as tuberculosis or nephritis, 
from the intercurrence of pregnancy, or from disease of the mammary 
gland. On no account should an infant be suckled at a breast which is 



Name 








































Date 


ofBir 


t? 


■>- 






















j8q 










MONTH OF AGE. 


GMS. 


LBS. 


1 2 3 4 5 C 


- 


8 9 10 11 12 


9530 
9070 
8620 
8100 
7710 
7260 
6800 
6350 
5900 
5440 
4990 
4540 
4080 
3630 
3180 
2720 
2270 


21 
20 
19 
18 
17 
10 
15 
14 
13 
12 
11 
10 
9 
8 
7 
6 
5 












































































































































































































































s. 


Mn 


ti 


e- 


H 


>n 


3 g 


n 


in 


t 




























** 










































































/ 
















































y 














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Id 


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1 






























































































l 






























































































\ 


>_ 

























































































































































































































































































































































































































































































































































































































































































































































































Fig. 30.— Chart showing the effect of pregnancy upon the weight of a nursing infant. The 
upper line is that of the patient ; the lower one is the average line for the first year. 



the seat of acute inflammation. Through many of the minor ills — mild 
attacks of bronchitis, pharyngitis, indigestion, and even malarial fever — 
mothers will frequently nurse their children without any seeming detri- 
ment to them or themselves. In acute illness of short duration, even if 
severe, it is usually better, unless we decide to wean altogether, to main- 
tain the flow of milk by the use of the breast-pump rather than allow it 
to dry up. The breasts may be pumped three or four times a day. 

In cases of sudden weaning, the food must in the beginning be very 
much weaker than for an artificially-fed child of the same age. If 
weaned at six months, the child should be put upon a food appropriate 
for a healthy child of one month ; if at nine or ten months, upon a food 
appropriate for one of three or four months. If this is done, the change 



MIXED FEEDING. 169 

can be made without causing much disturbance. When the infant has 
become somewhat accustomed, to cow's milk the strength of the food 
may be gradually increased. 

MIXED FEEDING. 

By mixed feeding is meant a combination of breast- and artificial-feed- 
ing. This may be resorted to in any case in which the milk-supply of the 
mother is insufficient, or when the drain upon her health is unduly great. 
In most cases it is better than entire artificial feeding, and there is no 
objection to combining the two ; but before allowing a mother partly to 
nurse and partly to feed her infant, one must be sure that the quality of 
the milk is good. This is to be determined by the principles given in the 
preceding pages. 

It is well from the very outset to accustom the infant to take one 
of its feedings, or at least to take water, from a bottle each day. In 
maternal nursing, the occasional feeding which is usually necessary, be- 
comes then an easy matter. If circumstances make it desirable to relieve 
the mother of night-nursing, or of one or more feedings during the day, 
this also can be accomplished without difficulty. If the child is being 
wet-nursed, the same plan is advisable, for it then becomes easy to put an 
infant upon the bottle entirely in the event of the wet-nurse leaving sud- 
denly — a not uncommon occurrence. If at any time the mother's health 
begins to suffer, she should be relieved of two or more nursings a day, and 
the bottle substituted. In this way she may be able to continue lactation 
for some time longer. When, however, the nursings have been reduced 
to only two or three daily, the milk should be examined frequently, as it 
is apt to deteriorate rapidly in quality. Mixed feeding is also necessary 
in many cases during the first few weeks, while the mother's milk is insuf- 
ficient in consequence of anything which has retarded convalescence after 
parturition. It often happens that the milk becomes abundant and of 
good quality when the mother is well enough to be up and out of doors, 
although it was previously scanty and of inferior quality. Two or three 
feedings a day from the bottle, help to bridge over this period and pre- 
vent the child's nutrition from suffering. In all cases of mixed feeding, 
the food should be the same as when the child is fed exclusively. 

ARTIFICIAL FEEDING. 

There are several fundamental principles which must be constantly 
borne in mind : 

1. The food must contain the same constituents as woman's milk, viz., 
fat, proteids, carbohydrates, inorganic salts, and water. 

2. These constituents must be present in about the same proportion as 
in good woman's milk. 



170 NUTRITION. 

3. As nearly as possible the different constituents should resemble 
those of woman's milk both in their chemical composition and in their 
behaviour to the digestive fluids. 

4. The addition to the food of very young infants of substances not 
present in woman's milk (e. g., starch) is unnecessary, contrary to the best 
physiology, and, if used in any considerable quantity, may be positively 
harmful. 

In the artificial feeding of infants, cow's milk is selected, as it furnishes 
all the necessary elements, although not in the proportions required by 
young infants. In adapting cow's milk to infant-feeding, it is necessary, 
first, to know the differences in the composition of cow's milk and woman's 
milk ; and, secondly, to devise the simplest means of overcoming these 
differences, in order to secure an infant-food which closely resembles 
average woman's milk in its percentages of fat, sugar, proteids, and salts. 
But this is not all. We can not feed all infants exactly alike, even though 
they are of the same age and weight. Their food must be adapted to their 
powers of digestion. In breast-feeding it has long been a matter of com- 
mon observation that an infant might thrive perfectly on the milk of one 
woman, and suffer immediately from indigestion when put upon that of 
another, although both were equally healthy. In the selection of a wet- 
nurse it has sometimes been necessary to try a dozen before one could be 
found whose milk agreed with the infant, or, in other words, whose milk 
contained the different ingredients — fat, sugar, and proteids — in propor- 
tions exactly suited to the child's condition. Hence it is necessary to vary 
the proportions of the different constituents in order to meet exactly the 
requirements of the individual infant. If cow's milk disagrees with an 
infant, the proper method of procedure is to try and discover which of 
the elements of cow's milk is causing the disturbance, and to change the 
proportions until we have a milk which the child can easily digest. Ke- 
duced to its lowest terms, the problem of infant-feeding consists, first, in 
obtaining the elements of the food separately ; and, secondly, in so com- 
bining them as to meet the needs of the case in hand. For this simplifica- 
tion of the problem the world is indebted to Botch. 

In feeding infants according to this plan, it is necessary to have a 
method of expressing in exact terms the composition of the food used. 
This can be done only by giving the percentages of the fat, sugar, pro- 
teids, and salts which the milk contains. The mere statement of the 
amount of milk or cream used conveys no definite idea, as these differ so 
much in their composition. Only by stating percentages can we record 
our own experience or compare our results with those of others. This 
new nomenclature, although perhaps a little difficult at first, is easily mas- 
tered, and is absolutely necessary in scientific infant-feeding. 

The Modification of Cow's Milk foe Healthy Infants dueing 
the Fiest Yeae. — In modifying cow's milk for infant-feeding, our cal- 



ARTIFICIAL FEEDING. 



171 



dilations are based upon the composition of good breast-milk, as deter- 
mined by the latest analyses : 





Woman's milk, 
average. 


Cow's milk, aver- 
age. 


Fat 


Per cent. 

4-00 
7-00 
1-50 
0-20 

87-30 


Per cent. 

3-50 


Sugar 


4-30 


Proteids 


4-00 


Salts 


0-70 


Water 


87-50 








100-00 


100-00 



We have, therefore, in cow's milk, an excess of proteids and salts, too little 
sugar, and of fat about the quantity required. Other conditions which 
must be considered are the presence of bacteria in cow's milk, its acid 
reaction, and the fact that its proteids are more difficult of digestion. 
The same is probably true of the fat in the condition in which we feed 
it, but to a much less degree. 

Fat. — The average amount of the fat of cow's milk which a healthy 
infant can digest varies from 2 to 4-5 per cent. It is rarely necessary in 
health to go either above or below these proportions. Beginning with 2 
per cent in the early days of life, the amount may be increased to 3 per 
cent at one month, and to 4 per cent at four or five months. No other 
modification in the fat is necessary. 

Sugar. — In woman's milk the percentage of sugar is remarkably 
constant under all conditions — between 6 and 7 per cent. In feeding 
cow's milk it is seldom required to have the sugar less than 5 and 
never more than 7 per cent. This is the simplest part of the modifi- 
cation. As the sugar in milk is simply lactose in solution, it is only 
necessary to calculate the amount required to be added to bring this 
up to the 6 or 7 per cent desired. The milk sugar should be first 
dissolved in boiling water, and, when it contains impurities, filtered 
through absorbent cotton. It should be prepared at least every second 
day, and in summer daily. It is more rational in theory, and certainly 
better in practice, to use milk sugar rather than cane sugar, since the 
former supplies what exists in woman's milk. It should be distinctly 
understood that the purpose of adding sugar to milk is not to sweeten 
the food, but to furnish the proper proportion of a soluble carbohy- 
drate necessary for the infant's nutrition. When, however, good milk 
sugar can not be obtained, cane sugar may be substituted ; the amount 
added must be but little more than half that of milk sugar on account of 
its sweeter taste, and greater liability to ferment in the stomach. 

Proteids. — The modification of the proteids is the most important 
change necessary in cow's milk, for it is the proteids which give most of 
the trouble to the infant digestion. In ordinary cases in health, a reduc- 



172 



NUTRITION. 



tion in the amount is all that is necessary. But for very young infants it 
is not enough to reduce the proteids to the proportion present in average 
woman's milk — 1*5 per cent. In the beginning, and even during the first 
months, we must go considerably below this point, usually to 1 per cent, 
and for the first few weeks to - 75 or even 0*50 per cent. The secret of 
success in feeding cow's milk, is to reduce the proteids at the start to a 
proportion which the infant can easily digest, and then gradually increase 
the amount. By the end of the first month the average child can take 

1 per cent, by the fourth month 1*5 per cent, and by the sixth month 

2 per cent. 

This reduction in the proteids is effected by dilution with water. In 
the following table is shown the result of various dilutions upon the pro- 
teids and inorganic salts : 





Cow's milk. 


Diluted once. 


Diluted twice. 


Diluted three 
times. 


Diluted four 
times. 


Proteids 

Salts 


Per cent. 

4-00 
0-70 


Per cent. 

2-00 
0-35 


Per cent. 

1-33 
0-23 


Per cent. 

1-00 
0-18 


Per cent. 

0-80 
014 







Inorganic Salts. — These, like the proteids, are excessive in cow's milk, 
and nearly to the same degree. When, therefore, milk is diluted as re- 
quired by the proteids, the salts will be nearly in their proper proportion, 
and they may be dismissed from separate consideration. 

Reaction. — The acidity of cow's milk may be overcome by the addition 
either of lime water or bicarbonate of soda. Of the former there is re- 
quired about one ounce to each twenty ounces of the food ; of the latter, 
about one grain to each ounce of the food. 

The subject of heating milk for the destruction of bacteria has been 
considered in a previous chapter (page 143). 

Milk Laboratories.— There have been established in Boston, New York, 
and Brooklyn, milk laboratories which undertake to furnish " modified 
milk " of any desired proportions, upon the prescription of physicians, 
exactly as drugs are dispensed by an apothecary. The elements used by 
these laboratories are: (1) cream containing 16 percent fat; (2) separ- 
ated milk from which the fat has been removed by the centrifugal ma- 
chine ; (3) a standard solution of milk sugar, 20 per cent strength. 
These contain fat, sugar, and proteids in the following proportions : 





Cream. 


Separated milk. 


Sugar solution. 


Fat 


Per cent. 

16-00 
4-00 
3-60 


Per cent. 

0-13 
4-40 
4-00 


Per cent. 


Sugar 


20-00 


Proteids 









ARTIFICIAL FEEDING. 173 

By combining these it is possible to vary the percentages of fat, sugar, 
and proteids in the milk to almost any degree desired, and to do this with 
very great accuracy. At the present time a separate modification of the 
inorganic salts is not attempted. The physician, in ordering the food, 
simply writes for the percentages of fat, sugar, and proteids desired, with 
the number of feedings for twenty-four hours and the quantity for each 
feeding. The food-supply for an entire day is delivered each morning 
in the bottles from which it is to be fed. The laboratory also under- 
takes to heat milk to any temperature that may be desired. The follow- 
ing is the form in which prescriptions are written : 

$ Fat 3 per cent. 

Sugar 6 " 

Proteids 1 

Alkalinity, limewater 5 per cent. 

Number of feedings 8 

Amount for each feeding 4 ounces. 

Heat to 167° F., 25 minutes. 

The establishment of the milk laboratory, for which the profession it 
indebted to Rotch, is a great stride in advance in infant-feeding, as it 
enables the physician to know what his patient is taking, at the same time 
making it possible to vary any one of the constituents of the food separ- 
ately, even to a fraction of one per cent, until the combination is reached 
which is exactly suited to the infant's digestion. With the assistance of 
the milk laboratory, infant-feeding can be done with something like sci- 
entific accuracy. The laboratory company has the direct oversight of the 
breeding, care, and food of cows and the handling of milk, to insure its 
purity, freshness, and cleanliness. The practical workings of the milk 
laboratories are so satisfactory that we shall doubtless see them established 
in all large 'cities. The only drawback is the expense. 

After two years' experience I have found the laboratory of great value 
in difficult cases of infant-feeding, and it soon becomes almost as much 
of a necessity to the physician practising among young children, as does 
the apothecary shop to the general practitioner.* 

As a general guide to the modification of milk for an average infant 
the following table is introduced, showing the changes required with the 
age of the child : 

* For fuller details regarding the milk laboratory, see Rotch, Archives of Paediatrics, 
February, 1893. 



174 



NUTRITION. 



Schedule for feeding an average healthy infant from birth upon modi- 
fied cow's milk, showing percentages of fat, sugar, and proteids, and 
the daily quantity. 



No. 


Age. 


Fat. 


Sugar. 


Proteids. 


Daily quantity. 


I 

II 

III 


First and second day 

Third to seventh day 

Two to four weeks 


Per cent. 

2 : 6 
2-5 
3-0 
3-5 
4-0 
4-0 
4-0 
4-0 
4-0 
3 5 


Per cent. 

50 
6-0 
60 
6-0 
6-0 
6-0 
7-0 
6-0 
5-0 
5-0 
4-3 


Per cent. 

: 60 
0-80 
1-00 
1-25 
1-50 
2-00 
2-50 
3-00 
3-50 
4-00 


Ounces. 

4- 8 
10-15 
20-30 
22-36 
28-38 
32-38 
34-42 
38-45 
40-50 
45-50 
45-50 


Grammes. 

125- 250 
310- 460 
620- 930 


IV 

V 

VI 


One to three months 

Three to four months 

Four to six months 


680-1,110 
870-1,180 
990-1,180 
1,050-1,300 
1,180-1,400 
1,240-1,550 
1,400-1,550 
1,400-1,550 


VII 


Six to nine months 


VIII 

IX 

X 

XI 


Nine to twelve months 

Twelve to fifteen months 

Fifteen to eighteen months. . 
Eighteen months (whole milk) 



In ordering milk for an infant, not only its age but its weight must be 
taken into account. One that at four months weighs as much as the 
average child at eight months, will usually be found able to take the 
quantity of food and also the percentages advised for the latter age. 
Again, there are some cases where the percentages of the milk may be 
increased more rapidly than in the schedule. As a rule, it is wise to 
increase the strength of the food just as fast as the child's digestion will 
permit. 

Modification of Milk at Home. — Inasmuch as milk laboratories are as 
yet accessible to but very few physicians, the problem presented is how 
to secure similar results by simple methods when milk is " modified " at 
home. If directions are followed, results may be obtained sufficiently 
accurate for practical purposes in the great majority of cases. However, 
considerable care and intelligence are necessary. 

The elements with which the formulae desired are most conveniently 
obtained are : (1) a 12-per-cent cream — i. e., one that contains 12 per cent 
fat; (2) an 8-per-cent cream ; (3) solutions of milk sugar of 5, 6, 7, 8, and 
10 per cent strength. 

The 12-per-cent cream may be obtained in the city by using equal 
parts of ordinary (20 per cent) centrifugal cream and plain milk ; in the 
country, by using two parts of ordinary skimmed or gravity (16 per cent) 
cream * and one part of plain milk ; or by taking the top layer of milk 
after standing five or six hours, in the manner described on page 142. 

The 8-per-cent cream may be obtained in the city by using one part of 
centrifugal (20 per cent) cream and three parts of plain milk; in the 
country, by using one part of gravity cream and two parts of plain milk ; 



* This is the ordinary cream twelve hours old. 
in the morning. 



It should be set at night and used 



ARTIFICIAL FEEDING. 175 

or by using the top layer of milk after standing five or six hours, as 
described on page 142. 

The sugar solutions are obtained as follows : 

A 5-per-cent solution: Dissolve an ounce of milk sugar* in twenty 
ounces of water, or one even tablespoonful \ in seven and a half ounces of 
water. 

A 6-per-cent solution : Dissolve one ounce of sugar in sixteen and a 
half ounces of water, or one even tablespoonful in six and a half ounces 
of water. 

A 7-per-cent solution : Dissolve one ounce of sugar in fourteen ounces 
of water, or one even tablespoonful in five and a half ounces of water.' 

An 8-per-cent solution : Dissolve one ounce of sugar in twelve and a 
half ounces of water, or one even tablespoonful in four and a half ounces 
of water. 

A 10-per-cent solution : Twice the strength of a five-per-cent solu- 
tion. 

With these ingredients it is a comparatively easy matter to make up 
with approximate accuracy the various formulas required. Formulas II to 
YI inclusive may be obtained from the 12-per-cent cream by simply dilut- 
ing this five, four, three, two and a half, and two times respectively with 
a 6- or 7-per-cent sugar solution. This will be plain from the following 
table : 

Formulae, obtained by diluting Twelve-per-cent Cream. 
Diluting 5 times % with 6% sugar solution = II : Fat 2*0$ ; sugar, 6% 



4 
3 

2i 
2 



H 



= 111: 


" 2-5#; 


= IV: 


" 3-0$; 


= V: 


" 3-5$; 


= VI: 


" 4-0^; 



rfo " " =V: " 3-5$; " Q% 



proteids, 0-60$. 


0-80$. 


" ■ l-00#. 


l-20#. 


1-30& 



In all these formulas it will be seen that the ratio of the fat to the 
proteids is three to one. Not only these formulas, but any intermediate 
ones with this ratio, may be derived by varying the dilution. The sugar 
may be easily modified, if desired, by using weaker or stronger solutions 
than those mentioned. With these formulas an average infant may be 
carried through the first six months, the period when accurate modifica- 
tion is most needed. 

Formula VII is obtained from an 8-per-cent cream by diluting once 
with a 10-per-cent sugar solution ; and in a similar way are derived other 
formulas in which the fat and the proteids bear the relation of two to one : 

* A convenient method is, to obtain from a druggist a box holding exactly one 
ounce of milk sugar. 

f One even tablespoonful may be calculated as three drachms. 

X By diluting five times is meant one part of the cream and five parts of the sugar 
solution, etc. 



176 NUTKITION. 



Formulae obtained by diluting Eight-per-cent Cream. 



Diluting once with 10$ sugar solution = VII : Fat, 4$ ; sugar, 7$ 
1J times " 7$ " " = XII: " 3$; " 6$ 

3 times " 7$ " " =XIII: " 2$; " 6$ 

7 " " 5$ " " =XIV: " 1$; « 5$ 



proteids, 2*00$. 
1-50$. 
1-00$. 
0-50$. 



It is in many cases desirable to use a lower percentage of fat than in 
the foregoing formulae without reducing the proteids. This may be done 
simply by diluting plain milk with a sugar solution. In these formulae 
the fat and proteids are nearly in the same proportions, viz. : 

Formula obtained by diluting Plain Milk. 

Diluting once with 8$ sugar solution = XV : Fat, 1 ■ 80$ ; sugar, 6$ ; proteids, 2 ■ 00$. 

3 times " 5$ " " =XVI: " 0-90$; " 5$; " 1-00$. 

7 " " 4$ " " = XVII: « 0-45$; " 4$; " 0'50$. 

" 11 " " 4$ " " = XVIII: " 0-30$; " 4$; " 0"34$. 

From the three fundamental formulae — 12-per-cent cream, 8-per-cent 
cream, and plain milk — we may readily derive almost any desired formula 
in which the proportion of fat is to that of the proteids as three to one, 
two to one, or where they are about equal. 

Following out the directions given in the preceding pages, the prepa- 
ration of an infant's milk should be somewhat as follows : The first thing 
to be decided is the formula to be used, then the size of each feeding and 
the number of feedings ; as it is always preferable to prepare at one time 
the entire amount of food required for twenty-four hours. Let us suppose 
we wish to give a milk containing fat 3 per cent, sugar 6 per cent, and 
proteids 1 per cent (formula IV), and that we require nine feedings of 
four ounces, or thirty-six ounces of food to be prepared. By referring to 
page 175 we see that this formula can readily be obtained by diluting a 12- 
per-cent cream three times with a 7-per-cent sugar solution. There will 
thus be required, nine ounces of the 12-per-cent cream and twenty-seven 
ounces of the 7-per-cent sugar solution. The cream may be obtained by 
taking four and a half ounces of centrifugal (20 per cent) cream and 
four and a half ounces of milk, or six ounces of skimmed (16 per cent) 
cream and three ounces of milk. For the sugar solution there will be 
required two ounces, or five and a half even tablespoonfuls, of milk sugar, 
to be dissolved in the twenty-seven ounces of boiling water ; or, if lime- 
water is to be added, one and a half ounces of limewater and twenty-five 
and a half ounces of boiling water. The full directions, written out for 
the guidance of a nurse, will then be as follows : 



Centrifugal cream, 4h ounces, j c skimmed cream, 6 ounces. 

Plain milk, A\ " \ or } plain milk, 3 " 

Milk sugar, 2 " or 5J even tablespoonfuls. 

Boiling water, 25$ " I A boiling water, 27 ounces. 

Limewater, 1£ ounce, S I bicarbonate of soda, 36 grains. 



ARTIFICIAL FEEDING. 



177 



Dissolve the milk sugar in the boiling water, filter through cotton, add 
the milk and cream, and mix all in a pitcher ; then add limewater or 
soda, and divide in nine bottles, stopping them with cotton. 

If the milk is to be heated for purposes of sterilization, directions for 
this should follow ; if not, the bottles should be rapidly cooled by stand- 
ing in cold water for fifteen minutes, during which the water should be 
changed once or twice, or kept cold by adding ice. The food should now 
be placed in an ice-chest, where it is kept until required. It should be 
warmed by placing the bottle in warm water, and shaken before it is fed. 

Although at first glance the preparation of food in the manner indi- 
cated may seem too complicated for general use, such is really not the 
case. The labour involved is not greater than when milk is prepared in a 
more irregular way, and any intelligent mother or nurse is fully compe- 
tent to carry out all the directions given when once they have been fully 
explained. 

To save the physician the trouble of calculating the exact quantity of 
each of the ingredients required for the formulae most used — viz., II, IV, 
and VII — there are given in the subjoined table the amounts needed for 
the preparation of twenty-four, thirty-two, forty, and forty-eight ounces 
respectively of food : 



No. 



II. 



IV. 



VII. 



Formula. 


Fat, 

Sugar, 

Proteids 


2-0% 


Fat, 

Sugar, 

Proteids 


6-0% 


Fat, 

Sugar, 

Proteids 


40$ 

7-0£ 
2-0$ 



Ingredients. 



Milk 

Cream (skimmed, 16$) 

Water 

Milk sugar, ounces 

Or milk sugar, even tablespoonfuls 

Milk 

Cream (skimmed, 16$) 

Water 

Milk sugar, ounces 

Or milk sugar, even tablespoonfuls 

Milk 

Cream (skimmed, 16$) 

Water 

Milk sugar, ounces 

Or milk sugar, even tablespoonfuls 



QUANTITY OF EACH INGREDIENT 
REQUIRED TO PREPARE THE FOL- 
LOWING AMOUNTS OF FOOD. 



24 oz. 32 oz. 40 oz. 48 oz 



1-J-OZ 
2i " 
20 " 

n u 



2 " 
4 " 

18 " 

n " 

3 " 

8 " 

4 " 

12 " 

n " 

3 " 



If oz. 
3i " 
26f " 
If" 
4 " 

2f " 
5i " 
24 " 
If " 
4 " 

10£ " 
H" 

16 « 
If " 

4 " 



2£oz. 
4* " 
334 " 

2 " 
5i " 

3* " 

6f " 

30 " 

2 " 



13* " 

n " 

20 " 

2 " 
5i" 



2f oz. 
5£" 
40 " 

31 " 
6* « 

4 " 

8 " 

36 " 

n " 

6i " 

16 " 

8 " 

24 " 

2f " 



If the centrifugal (20 per cent) cream is used, equal parts of milk and 

cream should be taken for formulas II and IV ; while for formula VII the 

proportions should be one-fourth cream and three-fourths milk. When 

limewater is to be added, it should replace the same quantity of plain 

water. The same is true of barley water, if used with formula VII, as is 

sometimes desirable, 
lo 



178 



NUTRITION. 



For older infants, able to take a stronger milk than formula VII, pro- 
portions similar to formula VIII (p. 174) may be obtained, thus : 

Milk, 24 oz. ; cream (16$), 7 oz. ; water, 19 oz. ; sugar, 2 oz. = 50 oz. 

Bottles and nipples. — The best style of bottle is that which can be 
most readily cleaned. The cylindrical bottles with wide mouths are now 
generally preferred. Some trouble in measuring the food is avoided if 
graduated bottles are used. On no account should bottles with any com- 
plicated apparatus be allowed. The best nipples are those of plain black 
rubber, which slip over the neck of the bottle. Those with a long rubber 
tube going to the bottom of the bottle should not be used, as it is prac- 
tically impossible to keep them clean. The hole in the nipple should be 
large enough for the milk to drop rapidly when the bottle is inverted, 
but not so large that it will run in a stream. When not in use, nipples 
should be kept in a solution of borax or boric acid. The most scrupulous 
care is necessary of both bottles and nipples. Bottles should first be rinsed 
with cold water, then washed with hot soap suds and a bottle-brush. When 
not in use they should stand full of water. Before the milk is put into 
them they should be sterilized by lying for twenty minutes in boiling water. 

Rules for artificial feeding. — A bottle should not be warmed over for 
a second feeding. A child should not be more than twenty minutes in 
taking its food, and should not be allowed to sleep with the nipple of the 
bottle in its mouth. It is preferable to have the child held in the arms 
of the nurse while faking its bottle. If this is not done, the bottle should 
at least be held in such a position that the child gets milk, and not air, 
from the bottle. It is even more necessary than in breast-feeding that 
rules as to frequency and regularity of meals should be observed. The 
following table gives the size of the meals, and the daily quantity of food, 
as well as the number of meals and intervals of feeding. This is con- 
structed for an average infant in health. An infant much above the 
average in weight must usually have its food graded accordingly. 

Schedule for Feeding Healthy Infants during the First Year. 



Age. 



3d to 7th day 

2d and 3d weeks 

4th and 5th weeks. . . . 
6th week to 3d month 

3d to 5th month 

5th to 9th month 
9th to 12th month.... 



No. of 
feed- 
ings, 24 
hours. 


Inter- 


Night 


val be- 


feed- 


tween 
meals, 
by day. 


ings (10 
P. m. to 
7 a. m.). 




Hours. 




10 


2 


2 


10 


2 


2 


9 


2 


1 


8 


2* 


1 


7 


3 


1 


6 


3 





5 


H 






Quantity for one 
feeding. 



1 -H 

14-3 

2£-3| 

3 -4£ 

4 -5* 
5J-7 
7£-9 



Grammes. 

30- 45 

45- 90 

75-110 

90-140 

125-170 

170-220 

235-280 



Quantity for 24 hours. 



Ounces. 

10-15 
15-30 
22-32 
24-36 

28-38 
33-42 
37-45 



Grammes. 

310- 460 
460- 930 
680- 990 
740-1,110 
870-1,080 
1,020-1,300 
1,150-1,400 



ARTIFICIAL FEEDING. 1?9 

Modification of Milk required by Particular Symptoms. — Regarding 
the exact indications according to which the fat, sugar, and proteids of 
milk are to be varied in infant-feeding, much is yet to be learned. The 
following are the points which experience has thus far led me to depend 
upon : 

If the sugar is too low, the gain in weight is apt to be slower than 
when it is furnished in proper amount. The symptoms most frequently 
indicating an excess of sugar are colic, or thin, green, very acid stools, 
sometimes causing irritation of the buttocks. In some cases, where the 
sugar is in excess, there is much eructation of gas from the stomach, and 
regurgitation of small quantities of food. 

An excess of fat is indicated by the frequent regurgitation of food in 
small quantities, usually one or two hours after feeding. It is sometimes 
shown by frequent passages from the bowels, which are nearly normal in 
appearance. In some cases the stools contain small round lumps some- 
what resembling casein, but really composed of masses of fat. In rare 
cases an excess of fat may be the cause of colic. The most constant in- 
dication that too little fat is given, is constipation with dry, hard stools; 
but it should not be forgotten that such stools are sometimes seen when 
the fat is not too low. To increase the fat above 4*5 per cent in feeding 
infants under six months old, simply because of constipation, is, I think, 
a mistake. In point of fact, I have rarely seen any advantage in carrying 
the fat above 4 per cent. 

The most reliable indication .that the proteids are in excess is the 
presence of curds in the stools. This condition is also a frequent cause 
of colic — indeed, of most of the colic of early infancy. Sometimes there is 
diarrhoea, but more frequently there is constipation, especially when the 
excess of proteids is great. This condition may be the cause of vomiting 
or the regurgitation of small quantities of food from time to time. Im- 
perfect digestion of the proteids may cause the same symptoms as when 
they are in excess, and the same may be true of the fat and of the sugar. 
Often the difficulty may be, not that the proportion of the different ele- 
ments of the food is actually in excess, but that more is given than the 
infant can digest at the time, and in any event the amount should be 
reduced. 

It is not practicable, even were it possible, to modify the milk so as to 
meet every temporary symptom of discomfort an infant may have. In 
general the most important indications may be summarized as follows : 
if not gaining in weight without special signs of indigestion, increase the 
proportions of all the ingredients ; if habitual colic, diminish the pro- 
teids ; for frequent vomiting soon after feeding, reduce the quantity ; for 
the regurgitation of sour masses of food, reduce the fat, and sometimes 
also the proteids ; for obstinate constipation, increase both fat and pro- 
teids. 



180 NUTRITION. 

The Use of other Food than Milk during the First Year. — 
In the discussion up to this point, nothing but the elements of milk 
has been considered. Upon these alone the infant can best be nour- 
ished during the greater part of the first year. The addition of other food 
should usually be deferred until the ninth or tenth month. At this period 
the power of digesting starch is sufficiently strong for the infant to receive 
some of its carbohydrates in this form, instead of all of it in the form of 
sugar, as has been previously the case. As starch is added, the sugar 
should be gradually reduced. The form of starch used may be a gruel 
made of barley, oatmeal, or arrowroot, or some of the farinaceous foods 
(page 156). If barley is used, the proper proportion to begin with, is to 
make the food about one third its volume of barley water of the strength 
mentioned on page 155. This will take the place of the same quantity of 
boiled water in the preparation of the food. It will then be added to each 
one of the feedings. By the eleventh or twelfth month the quantity of 
barley may be further increased by making the barley water stronger, 
rather than by using a larger quantity. The choice between the different 
cereals will depend upon the case. Where there is a tendency to constipa- 
tion, oatmeal water is to be preferred ; at other times barley. The only 
other thing to be advised during the first year is beef-juice (for prepara- 
tion, see page 153). This may be begun in the tenth or eleventh month. 
At first only half an ounce should be given daily, either alone or added 
to the milk. Later the daily quantity may be increased to two ounces, 
given with two of the feedings. 

Feeding in Difficult Cases. — Thus far we have dwelt upon the 
management of the food for healthy infants of average digestion, or, 
in other words, normal cases. There remain to be considered the modi- 
fications required for infants with feeble digestion — the difficult cases. 
This group is quite a large one. Some of these are delicate children 
with feeble digestion from birth, a class more numerous in the city than 
in the country; but there is a much larger number with chronic dis- 
turbances of digestion due to previous bad methods of feeding, or, what 
may be just as serious, improper nursing. In other cases the condition 
of feeble digestion is the result of unhygienic surroundings. In still 
others it is the consequence of previous attacks of acute disease of the 
digestive organs or of some general disease, such as influenza, whoop- 
ing-cough, or pneumonia. In all the problem is essentially the same: to 
adapt the food to an infant whose powers of digestion and assimilation 
are very feeble and easily disturbed. Time, patience, a careful study of 
individual cases, and close attention to details are necessary to secure the 
best results. The general care required by these children is equally as 
important as their food. This, however, is considered in the chapter on 
Malnutrition, and only the dietetic treatment will be discussed in this 
connection. 



ARTIFICIAL FEEDING. 181 

The difficulties are always greatest in the early months — viz., in giving 
the infant a start. When this has once been done, future progress is gen- 
erally easy. A food weakened to correspond to the child's power of diges- 
tion, may be able to do no more than repair the waste of the body, and 
sometimes not even that. The most common mistake is to use in the be- 
ginning a food so strong as to disturb the digestive organs. When once 
this has been done, all progress is difficult. These cases demand all our 
resources, and the difficulties are usually increased in proportion to the 
duration of the disorder. It may have existed so long that no form of 
artificial feeding, or even wet-nursing, will succeed. While these cases 
differ widely and each one must be studied by itself, there are certain 
principles of general application. 

1. The strength and quantity of the food are better gauged by the 
weight than by the age of an infant, but best of all by its power of 
digestion. This can only be determined by careful experimentation in 
each individual case. 

2. A larger quantity of a dilute food is usually better borne than a 
smaller quantity of one more concentrated. 

3. Up to the third month the rules as to frequency of meals should be 
the same as those for healthy infants. After this time the intervals 
should usually be shorter. 

Modification of Milk in Difficult Cases. — In the early months the usual 
symptoms presented by these cases are that they do not gain in weight, 
and that they show to a more or less marked degree the following signs 
of indigestion : the stools contain undigested food, usually lumps of 
casein ; there may be diarrhoea or constipation, usually the latter; there is 
frequently a regurgitation of small quantities of food, sometimes actual 
vomiting; there are usually flatulence and colic. In consequence of the 
foregoing conditions, sleep is disturbed, and the infants are cross and 
fretful much of the time. 

Xo proper gain in weight is to be expected until the indigestion is 
overcome, and this should be the first purpose in the management of such 
cases. 

So far as the elements of milk are concerned, it should be remembered 
that the sugar is least likely to be a cause of trouble, and it need rarely be 
reduced below 4 per cent, and never below 3 per cent. It is the proteids 
which give the most trouble, the fat coming next. For young infants 
with feeble digestion the proteids should always be reduced to 1 per cent, 
and usually to 0*5 per cent ; it may even be necessary to reduce to 0-25 
per cent for a short time. The fat can usually be taken in the propor- 
tion of 1 or 2 per cent, rarely more than the latter. For a short time it 
may be necessary to reduce the fat below 1 per cent. The proportions 
to be used under these conditions may be those of formula II, page 
175 : fat, 2 per cent ; sugar, 6 per cent ; proteids, 0-G per cent ; or, 



132 NUTRITION. 

if the 12-per-cent cream (page 174) is diluted with eleven parts of a 5-per- 
cent sugar solution, we obtain : 

/ Fat 1 * 00 per cent. 

Formula XIX ] Sugar 5'00 " 

(Proteids 0'30 

If we desire a relatively lower proportion of fat, we may use formula 
XIV (page 176) : fat, 1 per cent ; sugar, 5 per cent ; proteids, 0*50 per 
cent; or, diluting the 8-per-cent cream (page 174) with fifteen parts of 
a 4-per-cent sugar solution (one ounce to twenty-five ounces), we obtain : 

SFat • 50 per cent. 
Sugar. 4-00 
Proteids 0'25 

Usually, then, we should begin with one of the formulae having the low 
percentages mentioned, and with improvement in the symptoms gradually 
increase the fat and proteids by making the dilution less; if we began 
with formula XIX, instead of eleven parts of the sugar solution, using 
ten, nine, seven, five, etc. ; or, in a similar way, varying formula XX. The 
rapidity with which these changes can be made will of course vary with 
the progress of the case. 

For infants from four to ten months old presenting similar symptoms, 
a somewhat different modification must be made, particularly in cases of 
the marasmus type with long-standing trouble. As much difficulty may 
be experienced by them with the fat as with the proteids, and in some 
cases even more. But by most of these, as well as by the younger infants, 
sugar is well tolerated. We may begin with formula XVIII (page 176) : 
fat, O30 per cent ; sugar, 4 per cent ; proteids, 0-34 per cent ; after a 
time the strength of the food being gradually increased to formulas XVII, 
XVI, and XV by diminishing the dilution of the milk. Sometimes, how- 
ever, we may succeed better by beginning exactly as with younger infants, 
making the increase in strength usually with somewhat greater rapidity. 

The Use of Peptonized Milk. — Another plan which may be followed 
with infants who have great trouble in digesting the proteids of cow's 
milk is that of peptonizing the milk. For a description of the process, 
see page 148. It is important that a proper formula should likewise be 
used in these cases. For young infants such proportions as those of for- 
mula XIII, page 176, are appropriate — fat, 2 per cent; sugar, 6 per cent; 
proteids, 1 per cent. #In the beginning, the process may be continued for 
an hour; later, with improvement in the symptoms, reducing the time to 
half an hour, and then to fifteen and even ten minutes. It is preferable 
that the bottles of milk should be peptonized separately just before each 
feeding. The amount of the powder required is one grain of the ex- 
tractum pancreatis and three grains of bicarbonate of soda to each three 
ounces of the milk. The partial digestion of the milk may be continued 



ARITFIC1AL FEEDING. 183 

for several weeks, or until the stomach has in a measure regained its di- 
gestive power. There is a serious objection to its use for as long a period 
as four or five months, for in such a case the stomach gradually becomes 
less and less able to do its proper work. Which of the two methods of 
procedure — greatly reducing the amount of proteids or predigesting them 
— is the better one, will depend upon the individual case. 

The Addition of other Substances to Milk. — The opinion has long pre- 
vailed that the addition to milk of some mucilaginous substance, such as 
a gruel made from barley, oatmeal, or arrowroot, or gelatine and water, 
facilitates the digestion of the proteids of cow's milk by preventing in the 
stomach the coagulation of the casein in large solid masses which are dis- 
solved with such difficulty. The method of preparation has been to use 
these substances in the place of water, simply as diluents for milk, or more 
frequently to cook the milk with them for a short time — two to fifteen 
minutes — in order to obtain a more intimate combination with the casein. 
The substance most commonly employed has been a thin barley gruel. 
(For preparation, see page 155.) This may take the place of some of the 
plain boiled water in any of the formulae previously given, the usual 
proportion being to make the food from one fourth to one half its volume 
of the gruel. 

The recent experiments of Rotch and others throw a good deal of 
doubt upon the traditional belief in regard to the effect upon the casein 
of this treatment, and it is really questionable whether anything more is 
accomplished than by diluting with water. This method of prej:>aring 
milk is certainly of much less value than the careful modification of the 
milk constituents which has been previously considered. Still, it is a 
method which is useful in certain cases, whether the explanation which 
has been offered be the correct one or not. It should, however, be remem- 
bered that the starchy substance, whatever it may be, plays but a very 
small part in the nutrition of the infant ; first, because the amount of 
starch used is considerably below one percent of the food, the other ele- 
ments of the gruel being in such small proportions that they may be 
almost iguored ; and, secondly, because of the very feeble power of trans- 
forming starch into sugar which exists in the young infant. 

The Use of other Sugars than Milk Sugar. — It has been already stated 
that it is rare that there is difficulty in the digestion of sugar ; but such is 
sometimes the case. It is also true that there are exceptional instances 
in which milk sugar is not well borne, where cane sugar or even maltose 
(as in some of the malted foods) may be taken. Both of these are so 
sweet they must be used in proportions considerably smaller than those of 
milk sugar, and generally as temporary substitutes only. 

The addition of Beef Juice (page 153) to the milk where the digestion 
is so feeble as to require a great reduction in the proteids, is at times 
advantageous. From one half to two tablespoonfuls may be added to 



184 NUTRITION. 

each feeding. Instead of beef juice, some of the beef peptonoids men- 
tioned on page 154 may be used. 

The number of cases which can not be managed by simply varying the 
different elements of cow's milk, is small. In private practice, if the child 
can be taken in hand at the outset, the number is very small, the excep- 
tions being premature and delicate infants, which are reared under any 
circumstances only with the greatest difficulty. The difficulties are much 
increased where the disordered digestion has already lasted several weeks 
or months. They are greatest in institutions where many infants are 
brought together. As the weight is our most important guide to the suc- 
cess of any method of feeding, we must have accurate scales and weigh 
the infants twice a week, in order to determine as soon as possible what 
progress is made, so that a useless experiment may not be unduly pro- 
longed. For the first week or two no more than an arrest of the pre- 
vious loss in weight is to be expected. There can be no material gain 
until the symptoms of indigestion, colic, bad stools, restlessness, and vom- 
iting are greatly lessened or entirely gone. Until this is the case the food 
can not be increased in strength. The gain is almost always slow at first, 
amounting perhaps only to two or three ounces a week ; but it should be 
steady. Later, under favourable conditions, it should increase to six or 
eight ounces, or even more. 

For those children who do not thrive with an intelligent modifica- 
tion of cow's milk according to the plan above outlined, the thing most 
likely to succeed is the employment of a wet-nurse, although if the condi- 
tion of malnutrition has become firmly established even this often fails. 
Sometimes condensed milk succeeds, although its composition after dilu- 
tion (page 149) is similar to that which we have been employing (for- 
mula XVII or XVIII, page 176), the chief difference being the substitu- 
tion of cane-sugar for the milk-sugar. In rare cases infants seem unable 
to digest raw milk, but improve when put upon milk that has been steril- 
ized. Sometimes there is an advantage in withholding for a short time 
all milk constituents, and giving one of the malted foods with water, or 
animal broths. In apparently hopeless cases the most unpromising food 
or combination may occasionally succeed. I have lately seen an infant 
thrive upon plain milk undiluted, where all scientific modifications and 
additions had failed utterly. In every instance the general principle must 
be to begin with something which the child can digest and assimilate, 
and return to the usual proportions of the milk ingredients gradually, but 
just as soon as possible. We must often begin by doing what we can, not 
what we would like to do. We must avoid the danger of keeping an 
infant for a long time upon completely peptonized milk, also upon milk 
containing very low percentages of fat and proteids, like some of those 
referred to, and the continuance of food composed almost entirely of car- 
bohydrates where all milk has been withdrawn. 



FEEDING DURING THE SECOND YEAR. 185 

CHAPTER IV. 
FEEDING AFTER THE FIRST YEAR. 

HEALTHY INFANTS DURING THE SECOND YEAR. 

The physician should not relax his vigilance in the feeding of a child 
after the first year has passed. The ideas of the laity in regard to what a 
child can digest after it has outgrown an exclusive milk diet, are very 
erroneous. The majority of infants are given solid food too early and in 
too large quantities. Most of the attacks of indigestion during the second 
year are directly traceable to such gross dietetic errors. The diet of a 
healthy child during the second year should consist of milk, some farina- 
ceous food, bread, a small amount of animal food, such as beef or mutton, 
beef juice, eggs, and fruit. 

Milk should be the basis of the diet. There are a few infants for 
whom no modification of the milk is necessary, as they are able to digest 
without difficulty that containing 4 per cent proteids. The great ma- 
jority of infants do better if the proteids are kept at 3 or 3.5 per cent 
during the first half of the second year. If the fat is 4 per cent, chronic 
constipation, usually so troublesome at this time, may often be avoided. 
Since the child is now able to take a considerable proportion of its carbo- 
hydrates in the form of starch, it is not necessary to continue the large 
quantity of milk sugar given during the first year, and in many cases 
the sugar may be omitted altogether. However, where starch-digestion is 
so feeble that only a small quantity of farinaceous food can be allowed, it 
may be necessary to continue the milk-sugar during the entire second 
year. The formula? most generally useful during this period are : 



IX. At 12 months : 


Fat, 4-0#; 


sugar, 5 • 0% ; pro 


teids, 3-0%. 


X. " 15 


" 4-0$; 


" 5-0%; 


3-5fc. 


XI. " 18 


" 3-5$; 


" 4-3$; 


" 4-0$ (i. e., plain milk). 



We may obtain approximately these formulae by using the following 
proportions for one feeding of ten ounces : 

Formula IX. Milk, 6 oz. : cream (16%), 1 oz. ; water, 3 oz. ; sugar, 2 even teaspoonfuls. 
" X. " 8 " " " £ " " H " " 1 " teaspoonful. 

Instead of plain water in these formulae, we may use the same quantity 
of barley or oatmeal gruel or jelly. 

Farinaceous food : The easiest plan is to add this in the form of a gruel 
made of one of the cereals or farinaceous foods (page 15 G) ; the latter 
being partly dextrinized, require but ten to fifteen minutes' cooking. If 
these prepared flours are used, one even tablespoonful should be added to 
one pint of water, to make a gruel of about the proper strength. We may 



186 



NUTRITION. 



use with equally good results a gruel or jelly made from oats, wheat, or 
barley. If the grains themselves are used, they should first be soaked for 
six hours or over night in water which is thrown away, and then cooked 
for from four to six hours and strained through muslin. Two table- 
spoonfuls of the grains to one quart of water, cooked down to one pint, 
gives a jelly of about the desired consistency. Salt should always be 
added to make it palatable. 

During the first half of the second year children require from forty to 
fifty ounces (1,240 to 1,550 grammes) of fluid food daily; during the 
second half of the year from forty-five to fifty-five ounces. This quantity 
should be given in five feedings ; four of these being of equal size, one — 
usually the midday feeding, which is given in connection with the meat 
or meat juice — being smaller. 

Beef juice may be given as directed for the feeding during the latter 
part of the first year, the amount allowed being from one to three ounces 
daily. After the eighteenth month, if most of the teeth are present, rare 
scraped beef or mutton may be given at times in place of the beef juice. 
Not more than a tablespoonful should be allowed daily. After the eigh- 
teenth month, a soft-boiled fresh egg may also be given in place of the 
meat or meat juice, once or twice a week. 

A small piece of stale bread dried in the oven, or a piece of zwieback 
may be given, usually with the midday meal, after the child has most of 
its teeth. 

Fruit is a part of the diet too often omitted. Orange juice may be 
begun as early as the fifteenth month ; from half an ounce to two ounces 
may be given daily. A little later one or two tablespoonfuls of baked 
apple or two or three stewed prunes may be added. Both should be 
cooked until they are very soft. The baked apple should be given with- 
out sugar, and the prunes should be put through a sieve to remove the 
skins. The best time for giving fruit is about an hour before one of the 
milk feedings. 

The daily diet for a child of eighteen months should be arranged 
somewhat as follows : The first, second, fourth, and fifth meals should 
each consist of ten or twelve ounces of milk prepared with gruel, as above 
described, the fruit being given an hour before the second feeding. The 
third meal should consist of six or seven ounces of the milk and gruel, 
with beef juice, scraped beef, or egg, and dried bread. The form of 
farinaceous food may be varied from day to day, according to the child's 
taste. All other food may be advantageously omitted. Water only is to 
be allowed between the feedings. 

The milk for the twenty-four hours is best prepared at one time. The 
quantity needed for the different feedings should be put in separate bot- 
tles, as during the first year. What was said regarding the heating of 
milk during the first year for sterilization, applies also to the second year. 



FEEDING DURING THE SECOND YEAR. 187 

Children can usually be taught to drink from a cup at from twelve to 
fifteen months. 

DIFFICULT CASES DURING THE SECOND YEAR. 

The number of children whose nutrition is a matter of difficult) 7 dur- 
ing the second year is much smaller than during the first year ; yet there 
are cases in which the difficulties are just as great. Some of these are 
infants that have been very delicate from birth, and carried through the 
first year, only by the greatest effort. Others are healthy at birth, but 
their digestion has been badly deranged in consequence of improper feed- 
ing during the first year. Some are infants who did well until they were 
weaned, but from that time began to suffer from constant indigestion and 
malnutrition because they were put upon improper food, often undiluted 
cow's milk. In some the symptoms are the result of a severe attack of 
acute disease of the stomach or intestines during the first year. Many of 
them are rachitic. A frequent cause of trouble is that children have been 
put too early upon solid food, the mother often thinking that a child who 
is delicate is only to be built up by giving " strong food." Very often the 
difficulty is that the food has been excessive in starch, especially in the 
form of potato or oatmeal. 

Whatever may be the cause of the symptoms, all cases of feeble 
digestion or chronic indigestion of the second year are to be managed 
very much in the same general way. Usually the first thing to be done 
is to stop all solid food except the rare scraped meat. Starches must 
be reduced to the minimum or prohibited altogether. In most cases 
milk, meat, a.nd a little suitable fruit must constitute the diet. While 
it is undoubtedly true that the use of plain cow's milk often fails en- 
tirely, it is certain that nothing is more likely to succeed than cow's 
milk when properly modified. This must be continued as the principal 
diet, sometimes as the sole diet, for the greater part of the second year. 
The milk must be modified as for healthy infants who are from eight 
to twelve months younger than the patient under treatment. Thus a 
child of twelve or fourteen months, should be given milk prepared as for 
a healthy child of four or five months (formula YI, page 175) ; one of 
twenty to twenty-four months, as for a healthy child of from ten to 
twelve months (formula VIII, page 178). Milk containing a larger 
quantity of casein than in these formulas, is rarely digested unless partly 
peptonized, and this may be required even with the lower percentages. 
The daily quantity should generally be somewhat larger than for a 
young, healthy infant taking food of the same strength. The regular in- 
tervals of feeding should never be shorter than three hours, and in many 
cases four hours is to be preferred. The number of meals usually re- 
quired in the twenty-four hours is five. 

From few things is more striking improvement seen in these patients 



188. NUTRITION. 

than from the administration of rare meat-pulp, especially to those who are 
over eighteen months old. From one to two ounces may be given daily. 
Generally the proteids in the food have been previously deficient. Many of 
these children digest meat when given in this way better than they do the 
casein of the milk. Eaw beef juice may be used with the meat, or from 
time to time may take its place. 

The same fruits should be allowed as for healthy infants, the quantity 
being smaller. Inasmuch as it is with the starches that the greatest diffi- 
culty is usually experienced, the carbohydrates must be administered either 
in the form of milk-sugar or some of the malted foods. When starch is 
first allowed it should be given with some reliable preparation of malt. 

When the child is once well started and gaining steadily, the food 
may be gradually modified, until the diet recommended for healthy in- 
fants is reached. All changes must, however, be made very gradually, and 
it should never be forgotten that there is a constant disposition on the 
part of all mothers and nurses greatly to over-feed these children. 

FEEDING FROM THE THIRD TO THE SIXTH YEAR. 

Articles allowed. — From the following list the diet of a healthy child 
may be arranged : 

Milk. — This should be the basis of the diet ; most children require 
about one quart daily. This usually needs no modification, but if some- 
what difficult of digestion, it should be prepared as for the second year — 
six ounces of milk, one ounce of cream, and three ounces of water. The 
milk should usually be given warm. 

Cream. — This is of great value, especially when there is a tendency to 
constipation. From two to eight ounces may be given daily. It may be 
used upon cereals, upon potato, in broths, and mixed with milk. In many 
cases it is advisable to withhold milk and give only cream. 

Eggs. — These are a valuable form of proteid. They should be fresh, 
soft-boiled or poached, but never fried. Usually eggs should not be 
given oftener than every other day, as children readily tire of them. 

Meats. — Some form of meat should be given once a day. The best 
forms are beefsteak, mutton chop, and roast beef or lamb ; next to these 
the white meat of chicken, or fresh fish, which should be boiled or broiled. 
Beef and mutton should be given rare. 

Vegetables. — Potato may be given once a day, preferably baked, with 
the addition of cream or beef juice rather than butter. Of the green 
vegetables the best are asparagus tops, spinach, stewed celery, string 
beans, and fresh peas. One of these vegetables should be given daily — 
always well cooked and mashed. 

Cereals. — Nearly all these may be used — oatmeal, wheaten grits, homi- 
ny, rice, farina, and arrowroot. The most important part of the prep- 
aration is thorough cooking. If the grains are used, cereals should be 



FEEDING FROM THE THIRD TO THE SIXTH YEAR. 189 

cooked at least three hours, after having been previously soaked several 
hours. They should always be well salted, and given with milk or cream, 
but with little or no sugar. 

Broths and soups. — The meat broths are preferable to the vegetable 
broths. Xearly all varieties may be given. Plain broths are not very 
nutritious, but when thickened with arrowroot or cornstarch, and when 
cream or milk is added, they are very palatable, and at the same time a 
valuable addition to the diet. Beef juice may be used as directed for 
the second year. 

Bread and biscuits (crackers). — In some form these may be given 
with nearly every meal, better without butter until the fourth year, as 
for young children cream is a better form of fat. All varieties of bread 
may be allowed when stale ; also dried bread, zwieback, and oatmeal, 
Graham, or gluten biscuits. 

Desserts. — The only ones that should be allowed up to the sixth year 
are junket (page 152), plain custard, rice pudding without raisins, and, not 
oftener than once a week, ice-cream. Of the last three, the quantity 
given should be very moderate. 

Fruits. — An effort should be made to give fruit in some form every 
day. Oranges, baked apj)le, and stewed prunes are the most to be de- 
pended upon. Raw apples in most cases should not be given. Peaches, 
pears, and grapes (with seeds removed) may be given when thoroughly 
ripe and fresh, but only in moderate quantity. Special care should be 
exercised in the use of fruits in very hot weather, and in cities where they 
may not always be fresh. Berries are best deferred until children are six 
or seven years old, and even then should be given very sparingly. 

Articles forbidden. — The following articles should not be allowed to 
children under four years of age, and with few exceptions they may be 
withheld with advantage up to the seventh year : 

Meats. — Ham, sausage, pork in all forms, salt fish, corned beef, dried 
beef, goose, duck, game, kidney, liver and bacon, meat stews, and dress- 
ings from roasted meats. 

Vegetables. — Fried vegetables of all varieties, cabbage, carrots, potatoes 
(except when boiled or roasted), raw, or fried onions, raw celery, radishes, 
lettuce, cucumbers, tomatoes (raw or cooked), beets, egg-plant, and green 
corn. 

Bread and cake. — All hot bread and rolls ; buckwheat and all other 
griddle cakes ; all sweet cakes, particularly those containing dried fruits 
and those heavily frosted. 

Desserts. — All nuts, candies, pies, tarts, and pastry of every descrip- 
tion ; also all salads, jellies, syrups, and preserves. 

Drinks. — Tea, coffee, cocoa, wine, beer, and cider. 

Fruits. — All dried, canned, and preserved fruits ; bananas ; all fruits 
out of season and stale fruits, particularly in summer. 



190 NUTRITION. 

From the third to the sixth years four meals should usually be given 
daily and at regular intervals — e. g., 7 and 10.30 A. m. ; 1.30 and 6 p. m. 
The second meal should, in most cases, be smaller than the others. 

The following is a sample diet for a child of four years : 

First meal. — Half an orange, two tablespoonfuls of some cereal well 
salted with two or three tablespoonfuls of cream, a glass of milk, one 
piece of bread with a little butter. 

Second meed. — A glass of milk or cup of broth with bread or two or 
three biscuits (crackers). 

Third meal. — Two tablespoonfuls of finely divided steak or chop, one 
tablespoonful of baked potato, one tablespoonful of spinach, bread and 
butter, a cup of junket, water to drink. 

Fourth meal. — Milk with bread, or milk toast. 

From the list of articles given above, a sufficient variety in the diet can 
be secured. The only way for the physician to be sure that proper food 
is given to young children, is to write out for the guidance of the mother 
or nurse two lists somewhat similar to the above, of articles forbidden and 
articles allowed. This plan I have followed for several years with the 
happiest results. It is rarely safe to trust anything to the judgment of 
the mother. 

There are a few simple rules in feeding which should always be fol- 
lowed : 

A child must be taught to eat slowly and thoroughly masticate his 
food. The food must always be very finely divided, for, as a rule, mas- 
tication is very imperfect even up to the sixth or seventh year. . If the 
child is fed by the nurse, plenty of time should be taken for the meal. 
It is almost always the case that the food is given too rapidly. It is un- 
wise continually to urge children to eat when they are disinclined to do 
so at the regular hours of meals, or when the appetite is habitually poor, 
and under no circumstances should children be forced to eat. Indigesti- 
ble articles of food should not be given to tempt the appetite when ordi- 
nary simple food is refused, nor should these be allowed because of the 
notion that " the child must eat something." Food should not be allowed 
between meals when it is habitually declined at meal-time. If a child re- 
fuses to eat, and examination reveals no fault with the food prepared, it 
should seldom be offered again until the next feeding time. In all cases 
of temporary indisposition, no matter of w r hat nature, and during periods 
of excessive heat in summer, the amount of solid food should be reduced 
and more water given. If milk is the food, it should be diluted. 

FEEDING DURING ACUTE ILLNESS. 

Infants. — This is an important part of the treatment of every acute 
disease in childhood, but especially so in infancy. Whether the illness 
be one of the eruptive fevers, diphtheria, pneumonia, or influenza, all 



FEEDING DURING ACUTE ILLNESS. 191 

cases must be fed in about the same way. It is much easier by proper 
feeding to prevent disturbances of digestion in acute disease, than to allay 
them when they have been excited. In infancy this complication often 
turns the scale against the patient. One of the most important conditions 
which must be taken into consideration is, that in every severe acute 
illness, especially if it is of a febrile character, the power of digestion 
is much diminished. One evidence of this is the onset with vomiting ; 
another is the anorexia which accompanies the early stage of nearly all 
acute diseases, the child often refusing everything in the way of nourish- 
ment. We should respect this inclination and make it our guide in the 
treatment. On the other hand, there is great thirst from existing fever, 
and water is needed ; withholding this will often cause the temperature to 
rise even higher than before. 

In all acute febrile diseases the fundamental principle is, less food and 
more water. The total amount of food given in the twenty-four hours 
should be considerably less than in health. For infants the character of 
the food may generally be the same as in health, but should be given in 
very much greater dilution. For nursing infants this may be accomplished 
by making the nursing time shorter — four or five minutes, instead of the 
customary eight or ten — or a single breast, instead of both, may be given. 
Nursing children should be given water freely from a spoon or bottle. 
For those who are artificially fed, the amount of the ordinary food should 
be reduced by one third, or even one half, and this made up by adding 
water, at the same time allowing water freely between the feedings. In 
many cases the food must be not only diluted, but partly digested. 

The food should be given at regular intervals, never less than two 
hours, even if the amount taken at a single time is small ; otherwise the 
interval should be three hours. Eegularity should always be adhered to. 
If food is given oftener than every two hours, vomiting and indigestion 
almost invariably result. The water allowed between the feedings should 
be boiled, given frequently, and in liberal quantity. When stimulants are 
required, they may be mixed with the water given. The foregoing rules 
apply to the early stage of most of the acute diseases of infancy, and in 
many cases this plan may be followed throughout. 

Forced feeding — gavage. — Not a few cases, however, are seen in which, 
after a child has been several days sick, in consequence of delirium, stupor, 
sepsis, or some other serious condition, it may refuse all food or take so 
little that it is in danger of death from inanition. At this juncture forced 
feeding or gavage (see page G2) serves a most excellent purpose. Both 
food and stimulants can thus be introduced at regular intervals with slight 
disturbance, and lives saved which would otherwise be lost. If gavage is 
employed, the stomach should be first washed. The intervals of feeding 
should be made at least one hour longer than is customary in health, and 
usually predigested foods given. 



192 NUTRITION. 

In Older Children. — The same or similar conditions exist with reference 
to digestion in acute disease. These patients, however, are not so easily 
disturbed, and the disturbance of digestion is not so likely to be serious as 
in the case of infants. Even here the physician should direct the food to 
be given at regular intervals, usually not oftener than every three hours, 
but should never — as is so often done — order milk to be given to the child 
every time it asks for a drink. In most cases, for children under five 
years old, milk should be somewhat diluted, usually with limewater, and 
partly peptonized if the child's digestion is feeble. Children who do not 
take milk readily may be given beef tea, broth, gruel, or kumyss, but rarely 
ice-cream or jellies so frequently prescribed, as these, if given in any con- 
siderable quantity or very often, are likely to disturb the stomach and take 
away what little desire for food the child may have. Raw eggs are pala- 
table when beaten up with sherry, a little sugar, and cracked ice. Fruits, 
particularly oranges, grapes, and grape fruit, may be allowed in almost 
every febrile disease, but never given within two hours of a milk feeding. 

The water given may be plain boiled water, but better, in most cases, 
are some of the carbonated waters, Vichy, Seltzer, or Apollinaris, these 
being less likely to disturb the stomach. 

It is certainly a mistake to force food upon older children in any dis- 
ease in which their condition is not dangerous. But when there is sepsis, 
delirium, or coma associated with other dangerous symptoms, gavage may 
be resorted to with but little more difficulty, and with no less satisfactory 
results, than in infants. 



CHAPTER V. 
THE DERANGEMENTS OF NUTRITION. 

The derangements of nutrition form a distinct and a very large class 
in the ailments of infancy, particularly during the first year. The symp- 
toms are sufficiently definite and characteristic for them to be regarded 
as separate diseases, and to be discussed as such. In adults such symp- 
toms are seldom seen except in connection with organic disease. These 
cases are often very puzzling, and in a large number of them a diag- 
nosis of some constitutional disease, such as hereditary syphilis, or tuber- 
culosis, or organic disease of the stomach or intestines, is erroneously 
made. At other times the symptoms resemble those of acute toxaemia. 
The essential condition in all these cases is the inability of the infant to 
get from its food what its system needs. It can not digest or assimilate 
enough to support life. It is unable to replace from its food the daily 
waste of its tissues. The constructive metabolism is not equal to the 



ACUTE INANITION. 193 

destructive metabolism of the body ; the process is, therefore, essentially 
starvation, which may be rapid or slow, according to circumstances. 

The fault in these cases is partly with the digestion, but principally 
with the food. The problem is, to adapt the food to the digestion of the 
particular child under consideration. The solution is often very easy at 
first, but the difficulties multiply rapidly the longer the condition has 
lasted. It is therefore essential that the true explanation of the symp- 
toms should be recognised at the earliest possible moment. Changes 
occur so rapidly in very young infants that a mistake in diagnosis and a 
consequent delay of a few days, may be sufficient to determine a fatal re- 
sult. The outcome in cases of imperfect nutrition depends almost en- 
tirely upon their management. The condition is not one which tends to 
right itself. Spontaneous improvement or recovery rarely takes place. 
In order to recognise the condition and anticipate the result, nothing is 
so important as a close observation of the body- weight. A child whose 
nutrition is a matter of difficulty should be weighed regularly, in the early 
months twice a week, and once a week throughout the first year. If 
this is done, the first symptoms of failing nutrition are unerringly de- 
tected. If a child does not gain in weight something is wrong, and a 
steady loss in weight in an infant is a warning which should never be 
unheeded ; for, unless the conditions are changed, it is practically certain 
to continue, and generally with increasing rapidity, until the infant's 
vitality has been reduced to such a point that no means of treatment can 
restore it. The younger the child, the more rapid the loss, and the longer 
it has continued, the greater is the danger. 

For convenience of description these derangements of nutrition have 
been divided into three groups, differing, however, rather in degree than 
in kind. 

1. Cases of acute inanition, which are quite rapid, generally lasting 
from a few days to a few weeks. They are rare except in young infants, 
being most frequently seen in the first three months. 

2. Cases of malnutrition, in which the symptoms are much less severe 
than in the other groups, although they may be of long duration. While it 
is most common in the first two years, malnutrition may be seen at any age. 

3. Cases of marasmus. This is similar to inanition, but a much slower 
process, lasting usually for several months. It may be seen in infants of 
any age. 

ACUTE INANITION. 

Inanition, or starvation, is a condition depending upon lack of assimi- 
lation. It is common in early infancy, when it often simulates serious 
organic disease. In older children it is not so frequent, and not usually 
so obscure. In all the acute diseases of the digestive tract many of the 

symptoms are due to inanition. The cases considered in the present 
10 



194: NUTRITION. 

chapter, however, are those in which there is no such association, or where 
the digestive symptoms, strictly speaking, are not prominent. 

Etiology. — The essential cause of inanition is that the child does not 
get sufficient food, or that the food taken is not assimilated. It usually 
develops under one of the following conditions : (1) When a child refuses 
all food, whether from the breast or the bottle, or can be made to take 
only so small an amount that it is not enough to support life. The 
cause of this it is often impossible to discover. I have seen it in a variety 
of circumstances — once recently in an infant five months old, previously 
healthy, who was suffering from whooping-cough. This infant utterly 
refused the breast, and from the spoon would take less than two ounces a 
day. This continued for four days, at the end of which time its symp- 
toms were quite alarming. Gavage was then begun, and its life, I think, 
saved by this procedure. (2) When the food given is entirely inadequate, 
as when an infant is nursing upon a dry breast, or one in which the milk 
supply is so scanty that the child gets practically nothing. This is most 
frequent during the first two weeks of life. (See page 118.) I have occa- 
sionally seen it later, when an infant was put upon the breast of a wet- 
nurse whose milk, for some unexplained reason, had suddenly failed. (3) 
Where the character of the food is improper. Breast-milk may be not only 
scanty, but of very poor quality. On account of extreme poverty, the in- 
fant may be getting only tea, as I have known to be true in several cases 
before admission to the hospital. In some cases a very young infant may 
be fed entirely on starchy food. (4) Where the infant at birth has such 
feeble powers of digestion, beause premature or delicate, that it is unable 
to digest enough of the food given to maintain life. Sometimes this food 
is breast-milk, which, though abundant, is of inferior quality and can not 
be assimilated. Very often it is some proprietary food. (5) When a sud- 
den change of food is made to one so difficult of digestion that the child 
is unable to assimilate it. This may happen after sudden weaning. In 
such cases the symptoms of inanition are mingled with those of acute in- 
digestion, but the former usually predominate. 

In children over one year old, and sometimes in younger ones also, the 
symptoms of inanition follow those of some acute disease, such as influ- 
enza, malaria, pneumonia, or even otitis. Although they may recover 
from the acute process, the general vitality is so much lowered that as- 
similation is not sufficient to replace the waste of the body. 

Symptoms. — The mode of development depends upon the antecedent 
condition. In young infants inanition often follows malnutrition where 
perhaps there has been nothing noticeable except a gradual loss in 
weight ; and if the weight has not been watched, it may be observed only 
that the infant has not been doing well. Severe symptoms may come on 
quite suddenly, and if the nature and the gravity of the condition are not 
appreciated the case may terminate fatally in two or three days. The 



ACUTE INANITION. 195 

loss in weight is now rapid, amounting often to three or four ounces a 
day. The temperature is variable : in the newly-born it is often high, but 
it may be subnormal, or it may be normal. The pulse is always weak 
and rapid. The extremities are usually cold and the peripheral circula- 
tion poor. There is marked general prostration. The skin may be dry, 
or it may be covered with a clammy perspiration. There is extreme 
pallor, and in the most severe form there is cyanosis. This may be 
marked and may last for two or three days, gradually deepening until 
death occurs, or it may disappear entirely and recovery follow. Cyanosis 
may be present in children who have previously cried well and in whom 
there is no suspicion of atelectasis. The respirations are rapid and may 
be irregular. There may be constant worrying and fretfulness, or a con- 
dition of semi-stupor, in which the child makes no sign of wanting food. 
The fontanel is sunken and the pupils are often contracted. The stools 
contain undigested food, or if predigested foods are given they seem to 
pass through the intestines unchanged. The bowels usually move fre- 
quently, although in rare cases there may be constipation. When all food 
is refused for two or three days the stools may resemble meconium, as I 
once saw in a child six months old. While no desire for food is mani- 
fested, infants will sometimes swallow food when it is offered, retaining 
everything given for several feedings, when the whole quantity is vomited. 

The course of the disease depends much upon the age of the infants. 
Those under one month succumb most quickly. In them the symptoms 
sometimes last but two or three days, seldom more than a week or ten 
days, the children simply drooping steadily until death occurs. With 
proper treatment complete recovery may take place in a week. In 
older infants the progress, whether upward or downward, is usually less 
rapid. 

Prognosis. — The outcome of these cases is always uncertain. In few 
conditions is it more so. It is hard for one who is not familiar with the 
condition to appreciate the great and even the immediate danger in which 
a young infant may be from inanition, especially in the absence of both 
vomiting and diarrhoea. It is difficult to estimate the gravity of an indi- 
vidual case except after twenty-four hours' observation. The best of all 
guides is perhaps the weight. Where the loss is several ounces each day the 
chances of recovery are small. The presence also of frequent vomiting 
or of diarrhoea makes the outlook very bad. A high temperature, very 
marked relaxation, copious perspiration, cold extremities, and cyanosis 
are all bad symptoms. 

Diagnosis. — Inanition is distinguished from malnutrition by its greater 
severity, and from marasmus by its more acute character. The usual mis- 
take is that of confounding inanition with some local or constitutional 
disease. It may be mistaken for acute indigestion, meningitis, gastro- 
enteritis, pneumonia, and for some of the fevers. The temperature when 



196 NUTRITION. 

elevated is especially likely to mislead. This is not often seen except 
where little or no food is taken or retained. 

Treatment. — The existence of inanition in young infants presupposes 
only the feeblest powers of digestion and assimilation. If possible, a good 
wet-nurse should be secured, for in most of the cases the time for action 
is so short that there is no opportunity to experiment with artificial feed- 
ing. This is one of the few conditions in which wet-nursing is almost 
indispensable. If a wet-nurse can not be obtained, a diluted milk like 
formula XIII (page 176) may be given after being peptonized for two 
hours. If food is not readily taken, it should be given by gavage. This 
is frequently necessary, as very many of these infants will not take food 
at all, or only in such small quantities as to be insufficient for nourish- 
ment. If there is vomiting, even greater dilution may be required. If 
food so prepared is not retained, kumyss, whey, animal broths, and malted 
foods may be tried in succession. Wherever the symptoms have come on 
very rapidly, temporary improvement sometimes results from the hypo- 
dermic use of a one-per-cent saline solution, two ounces every five or 
six hours. The amount of food actually taken in the twenty-four hours 
should be noted, as it is often found to be only one fourth that which 
is actually needed for the child's nutrition. 

The general treatment includes stimulants and the careful regulation 
of the body temperature. If there is fever, sponging with tepid water, 
cold to the head and heat to the extremities may be employed. If the 
temperature is subnormal, the child should be rolled in cotton and sur- 
rounded by hot water bottles, or put into an incubator. Stimulants are 
required in most cases, the best form being some of the beef peptonoids 
with wine, given in frequent, small doses. As soon as the child begins to 
improve, one must be careful about increasing the food too rapidly, for 
renewed vomiting with an aggravation of all the other symptoms, is almost 
certain to follow such a mistake. 

In older infants the symptoms of inanition may develop when a child 
who is suddenly taken from the breast absolutely refuses all other forms 
of nourishment. This may continue for three or four days until the 
symptoms are quite alarming. For such cases gavage may be employed, 
and formula XII or XIII (page 176) given, peptonized two hours. 

When inanition develops in children over a year old it is usually after 
an attack of some acute disease. They lie in a dull, apathetic condition, 
sometimes with subnormal temperature, showing no desire for food. The 
circulation is poor, the skin dry ; there may be small petechias upon the 
abdomen; bedsores form with great rapidity over the heels, sacrum, or 
occiput. There may be no vomiting, and the stools may appear quite 
good. Something seems to be needed here to arouse the slumbering cells 
to activity, and massage, external heat, hot baths, together with careful 
feeding, temporarily upon predigested foods, are means by which a few 



MALNUTRITION. 197 

of these cases can be saved ; but the majority sink gradually and die of 
exhaustion, the autopsy showing no sufficient explanation of the symp- 
toms. 

MALNUTRITION. 

Cases of malnutrition are exceedingly common, and occupy a large 
part of the time and attention of one engaged in practice among chil- 
dren. Although these children can not be said to be actually ill, they 
are very far from well, and their condition is often the cause of the great- 
est solicitude on the part of anxious parents, not only from the existing 
state of health, but from the apprehension of the development of some 
serious organic or constitutional disease, especially tuberculosis. 

Etiology. — Malnutrition may depend upon inherited conditions. Cer- 
tain children are delicate from birth, possessing only feeble physical 
vitality, but without giving evidence of any actual disease. They are 
often the offspring of parents of delicate constitution, or of those with 
inherited tuberculosis, gout, syphilis, or alcoholism. Very many city chil- 
dren are included in this group. They are a product of modern life, in 
whom is seen a too highly developed nervous organization with a corre- 
sponding amount of physical deterioration. In another group of cases the 
children are premature or very small at birth, weighing perhaps only three 
or four pounds. Many cases are traceable to improper feeding or equally 
poor nursing during the first few months. These children get a bad start 
in life, and on that account are handicapped throughout infancy. In 
many cases malnutrition develops as a result of the patient's surroundings. 
While this is common among the poor, it is not rare among the better 
classes. One of the most frequent causes is the pernicious custom of 
keeping infants in close apartments where the thermometer ranges from 
72° to 78° F., and where the greatest anxiety is constantly felt lest the 
children take cold. Such infants may lose in weight, become anaemic, 
and exhibit all the signs of malnutrition where nothing else is wrong ex- 
cept the conditions mentioned. In infants, malnutrition often depends 
upon some previous acute disease, especially of the stomach and intes- 
tines, and sometimes of the lungs. 

In children who are over two years old the condition of malnutrition 
may be due to any of the factors above mentioned — inherited feebleness 
of constitution, bad feeding and its resulting indigestion, too little fresh 
air, and close confinement indoors. It is, however, at this period much 
more frequently than in infancy, dependent upon some previous acute 
disease. This may have been acute broncho-pneumonia, acute ileo-colitis, 
influenza, malaria, or any of the eruptive fevers. As a result, an im- 
pression is left upon the child's constitution which lasts for months, 
often for years, and which manifests itself not by any special local symp- 
toms, but by a general condition of debility or malnutrition. Sometimes 
such diseases, instead of being directly the cause of the symptoms, are 



198 NUTRITION. 

the occasion which brings out some latent inherited taint or constitu- 
tional weakness in children who up to this time, perhaps, have appeared 
exceptionally healthy. In other cases malnutrition depends upon faulty 
methods in education, especially upon overpressure in schools. 

Symptoms. — In infants. — In weight these children are much below 
the average, and the weight is stationary or the gain very slow, often only 
five or six ounces a month at a period when it should be from one to two 
pounds. In a case recently under treatment, a child at fourteen months 
weighed but eight and a half pounds. This infant at birth weighed three 
and a half pounds, but in the course of a few weeks the weight dropped to 
two pounds. Not only is the weight low in these cases, but the growth 
of the body in every respect is delayed. At one year, the length is often 
only four or five inches more than at birth. Dentition is usually but not 
invariably delayed. I have repeatedly seen children suffering from a very 
marked degree of malnutrition in whom dentition was normal. In mus- 
cular development such children are always very backward, often not 
sitting alone until they are a year old, making no attempt to stand until 
the middle of the second year, and not walking alone until the end of the 
second or the middle of the third year. The muscles are soft and flabby 
and the ligaments weak. 

Anaemia is invariably present, and varies much in degree, being rarely 
extreme. The circulation is commonly poor, the hands and feet are fre- 
quently cold. In many children the skin is unnaturally dry ; in others 
there is a disposition to excessive perspiration, particularly about the head. 
Nervous symptoms are usually present. These children are restless, fret- 
ful, and irritable ; they sleep badly during the day, and often worse at 
night. Enlargement of the lymph glands is common, especially in the 
neck. The cervical adenitis may have started from a slight catarrhal 
cold, but the glands continue to swell after this has subsided and may 
remain enlarged for months. 

One of the most characteristic things about these infants is their feeble 
powers of digestion and assimilation. Unremitting care and constant 
watchfulness are required to keep them up even to a moderate standard 
of health. The most trivial changes in food may upset them. At- 
tacks of acute indigestion are usually brought on by overfeeding — the 
mistake which is almost invariably made by mothers who are discouraged 
with the slow progress made, and are anxious to make their children grow 
fat and strong. The balance is so delicately adjusted that the slightest 
deviation from proper rules of feeding, either as to the quality of the 
food or quantity given, is immediately followed by an attack of acute 
indigestion, often by severe diarrhoea. As a result, the child may lose as 
much in two or three days as it has gained in a month or more. These 
acute attacks in summer not infrequently prove fatal. Not only do these 
patients have but little resistance to acute disturbances of the stomach 



MALNUTRITION. 199 

and intestines, but any acute disease is serious — measles, whooping-cough, 
and pneumonia being especially fatal. 

Among the poor or in institutions, cases of malnutrition like those 
described, if they are under nine months old, are almost certain to go 
on from bad to worse until they have reached the condition described 
as marasmus. Between this and malnutrition no sharp line can be 
drawn ; they are rather different degrees of the same general process. 
In private practice, where it is possible to have the best care and sur- 
roundings, with the co-operation of an intelligent mother or nurse, a 
very large number of these infants can be reared. After the second year 
has passed the problem becomes a much simpler one, and if infectious 
diseases and other attacks of acute illness can be avoided, the probabili- 
ties are in favour of the child's growing to maturity and becoming 
stronger each year. 

In older children. — In general appearance these children are thin, 
spare, and very often undersized, particularly if the condition is constitu- 
tional or hereditary. In other cases they are taller than the average for 
their age, and their symptoms are often attributed to too rapid growth. 
One of the most striking things about children suffering from malnutri- 
tion is their vulnerability. They " take " everything. Catarrhal processes 
in the nose, pharynx, and bronchi are readily excited, and, once begun, tend 
to run a protracted course. There is but little resistance to any acute in- 
fectious disease which the child may contract. One illness often follows 
another, so that these children are frequently sick for almost an entire 
season. Their muscular development is poor, they tire readily, are able to 
take but little exercise, and their circulation is sluggish. Nervous symp- 
toms are usually present. Many of these would be called nervous children. 
They are cross, fretful, and any unusual excitement produces an effect 
which lasts for some time ; for example, after a children's party or a 
Christmas tree they may lie awake half the succeeding night, and may 
be really ill for two or three days. Their sleep is usually disturbed and 
restless ; they waken frequently, and occasionally suffer from night- ter- 
rors. At a later age they are favourable subjects for chorea, neuralgia, and 
all functional nervous disorders. 

Digestive symptoms, if not constant, are very easily excited. In fact, 
they do not suffer so much from chronic indigestion as from a delicate or 
feeble digestion, which is easily upset by the slightest deviation from 
the regular routine. Children of five or six years have to be fed as care- 
fully as infants of eighteen months or two years. The appetite is usually 
poor, and mothers are distressed because their children eat so little, yet, 
when food is urged upon them, attacks of indigestion follow with singular 
uniformity. The tongue is slightly coated the greater part of the time. 
The bowels are apt to be constipated, apparently more from lack of mus- 
cular tone than from anything else. From time to time, from slight 



I 



200 



NUTRITION. 



causes, such as exposure to cold, or even fatigue, there may be large quan- 
tities of mucus in the stools for two or three days at a time, although this 
is not a prominent feature of most of these cases. When they are not fed 
with the greatest care these children suffer constantly from indigestion. 
A moderate amount of anaemia is always present, and in some cases this is 
one of the most striking features of the disease. In very many children 
with a marked disturbance of nutrition, there is an excessive elimination 
of uric acid. 

The duration of these cases depends very much upon the cause. If 
the cause is constitutional or inherited, the condition may last throughout 
childhood. Where it follows some acute illness it commonly lasts for a 
few months only ; but the effect of an acute attack of broncho-pneumonia 
or of ileo-colitis may last for years. If the malnutrition is the result only 
of the child's surroundings, like the confinement incident to city life, very 
rapid improvement and prompt recovery may follow a removal to the 
country. 

Diagnosis. — The physician should not be too ready to make a diagnosis 
of simple malnutrition. Before accepting such a diagnosis, he should 
examine the child with the greatest care, to exclude the common organic 
and constitutional diseases of children. Much regarding inherited con- 
stitutional tendencies can be learned from the family history and from the 
condition of the other children. In the first place, tuberculosis, syphilis, 
and rickets should be excluded ; then chronic malaria and the diseases of 
the blood ; and, finally, organic diseases of the lungs, heart, stomach, in- 
testines, liver, and kidneys. Even malignant disease, though rare, should 
not be overlooked. It may take careful observation for several days, and 
sometimes for weeks, with repeated physical examinations, before all these 
conditions can positively be excluded. 

The next step in the diagnosis is to discover upon which one of the 
many possible causes, malnutrition depends. In my own experience in 
private practice the proportion in infancy has been about as follows : 
sixty per cent due to improper feeding or nursing ; twenty per cent to 
improper surroundings, particularly to hot rooms and want of fresh air ; 
and twenty per cent to inherited constitutional conditions. In other 
words, most of these children are born healthy, but become ill or delicate 
in consequence of improper management. 

In older children, after excluding constitutional and local diseases, 
the whole life of the child must be investigated to discover the funda- 
mental condition which is at fault. It is often difficult, and sometimes 
impossible, to get at this primary factor, for in cases of long standing 
there may be symptoms connected with almost every function of the 
body. One should scrutinize closely the quality and quantity of food 
given, the amount of sleep, the hours of study and recreation, the 
amount of exercise in the open air, and the psychical conditions sur- 



MALNUTRITION. 201 

rounding the child. Usually we can decide which is the most important 
factor in the case. 

Prognosis. — An accurate diagnosis carries with it the data for prog- 
nosis. If the cause can be discovered, and if it is one which can be 
removed, the prospects are good for improvement, and usually for com- 
plete recovery. The longer the cause has been operative, the more pro- 
found will be the general disturbance of nutrition, and the longer the time 
required for improvement. Cases due to improper feeding or surroundings 
usually improve immediately when a proper regime is instituted, and the 
worse the previous management of the case has been the more marked 
is the improvement to be expected. In these cases everything depends 
upon the fidelity with which the directions given in regard to diet and 
surroundings can be carried out. The cases which offer the greatest 
difficulties are those in which the condition of malnutrition depends upon 
an inherited delicate constitution ; although these may improve, they 
require the closest attention throughout childhood. Without the co- 
operation of an intelligent and devoted mother, or an experienced nurse, 
very little progress can be made. 

Treatment. — This is a problem of nutrition to be solved by diet and 
general management, drugs occupying a very small place. 

In infancy. — In very young infants treatment is chiefly a question of 
feeding. If possible a wet-nurse should be secured. If this is impossible, 
artificial feeding should be carried on according to the rules given in 
the chapter upon the feeding of delicate children and those with feeble 
digestion. (See page 180.) These children often do fairly well during 
the first year, but after this time has passed mistakes are most frequently 
made, on account of the failure to appreciate the fact that, although 
over twelve months old, these children in point of development resemble 
healthy infants of four or five months, and are to be managed as such. If 
possible, weaning should be deferred until the sixteenth or eighteenth 
month, or at least partial nursing should be continued until that time. 
When cow's milk is begun it should always be very largely diluted, usually 
modified as for a healthy infant a month old. (See formula IV, pages 174, 
175.) It is surprising to see with what uniformity the giving of cow's 
milk, pure or slightly diluted, will produce attacks of indigestion in these 
infants. I have seen a single feeding in which one ounce of milk was 
given, and that diluted three times, produce a violent attack of acute indi- 
gestion which proved well-nigh fatal. Feeding during the entire second 
year should be carried on very much as in ordinary healthy children from 
the sixth to the twelfth month. A deviation from this rule almost inva- 
riably results disastrously. One must be guided in the amount and char- 
acter of the food not so much by the child's age as by its digestive capacity, 
and in most cases this is much feebler than the mother or even the physi- 
cian supposes. In many of these cases, cow's milk — for them the most 
17 



202 NUTRITION. 

valuable of all foods — has been excluded from the diet, when the only 
trouble is that it has not been given in sufficient dilution. For some 
children it must be partly peptonized during periods when digestion is 
especially feeble. 

Next in importance to diet is the question of fresh air. Oxygen is the 
best of all tonics for these children. Often they will not improve with 
any variation in diet until fresh air is allowed. Then increased digestive 
power is seen in the course of a few weeks, sometimes in a few days. 
The natural tendency of a mother who has a delicate infant, or one suffer- 
ing from malnutrition, is to house it closely and never allow it a breath 
of fresh air. Even in winter this may be obtained by changing apart- 
ments, or by airing in the room with the windows open. In the beginning 
this should be done for a few minutes only, the time being gradually in- 
creased to two or three hours each day. The child should be clothed as 
for the street, and, if necessary, hot bottles should be placed at the feet. 
Experiments which I have lately made in the hospital with these delicate 
infants, have proved conclusively the value and safety of this plan. 

Cold sponging is another valuable tonic. After the morning bath is 
given, at 90° F., the entire body should be sponged for a moment with 
water at a temperature of 60°, or even 55° F. This produces a certain 
amount of shock and causes loud crying, which is of itself beneficial. 
How frequently this should be used will depend upon the reaction follow- 
ing it. If the child remains blue and cold for some time afterward, the 
cold sponging should not be repeated. If there is a good reaction and 
improved colour, it may be used daily. 

Friction and massage are useful in many cases. The child should be 
laid upon the lap of the nurse, if possible before an open fire, and should 
always be covered with a blanket. The entire body may now be rubbed 
for ten or twenty minutes with the bare hand, or, better, with cocoa butter. 
Simple rubbing may be used, or the usual movements of massage em- 
ployed. If the latter, they should be very gentle at first, and only for a 
short time. Professional operators are inclined to be too energetic for 
little children. There is no advantage in rubbing with cod-liver oil in- 
stead of cocoa butter, while the odour makes it decidedly objectionable. 

The only tonics I have found of much value are alcohol, nux vomica, 
and cod-liver oil. Alcohol may be given in the form of port or sherry 
wine. Nux vomica may be given alone or with the wine. Cod-liver oil 
is too much used in these cases, and in too large doses. Many of these 
infants can not take it at all. It should rarely be given when the tongue 
is coated and the appetite very poor. The dose should always be small — 
e. g., ten drops of the pure oil three times a day, or twice as much of an 
emulsion. In these doses it may be given for a long time without dis- 
turbance. 

The secret of success in treating cases of malnutrition is, to hold the 






MALNUTRITION. 203 

patient to a regular routine in feeding, sleep, and in everything relating 
to his life. Experiments are nearly always unfortunate. The physician 
should lay down in writing for the guidance of the mother, specific rules 
with regard to the amount of food, the time at which it is to be given, the 
hours of bathing, sleep, and airing, and should insist upon their rigid 
enforcement. Good results are obtained only by constant watchfulness, 
and although they may not be seen at once, they are in most cases sure to 
come if the mother will co-operate. In my own experience no class of 
patients have given me so much satisfaction as cases of malnutrition in 
infancy. 

In older children. — The same general principles are to be applied to 
them as to infants. The diet is of the first importance. Only the sim- 
plest, plainest, and most easily digested articles of food should be given. 
Milk, beef, eggs, bread, and fruit should form the staple diet. All sweets, 
pastry, highly seasoned food, candy, nuts, tea, and coffee should be abso- 
lutely prohibited, and, in fact, none of the articles mentioned as " forbid- 
den " on page 189 should under any circumstances be permitted. When 
the appetite is poor and simple food not well taken, the child should not 
be allowed to take indigestible articles for the sake of eating something. 
Nothing should be given between meals, and regular hours of feeding must 
be followed. Usually I have found three meals a day, for children over 
three years old, better than the practice of giving more frequent feedings. 
But this is not always the case. Under no circumstances should children 
be coaxed, urged, or hired to eat ; much less should they be forced to do so. 
There is a popular misapprehension in regard to the variety in diet which 
children need. Most cases do better when a very simple and fairly uni- 
form diet is continued. 

The general habits of children should be directed ; there should be 
regular and early hours for retiring, freedom from undue excitement, 
and interest should be awakened in out-of-door amusements. Children 
should be kept as much as possible in the open air ; usually they do much 
better if they can be in the country during the entire year. Only a limited 
amount of reading and study should be allowed ; and if children are at 
school, care should be taken that overpressure is not the cause of the 
symptoms, particularly in an ambitious child. The cold sponging given 
in the morning, as described on page 55, is extremely beneficial to chil- 
dren who are prone to take cold readily. Massage is useful for the benefit 
which it affords to the chronic constipation which is so frequently a symj> 
tom of malnutrition. 

Of the tonics, iron, arsenic, and cod-liver oil are required in most cases, 
and the amount and combination may be varied from time to time, with 
the season of the year and the condition of the child's digestion. 



204 NUTRITION. 

MARASMUS. 

Synonyms : Athrepsia, infantile atrophy, simple wasting. 

Wasting is a symptom of many conditions in infancy. It occurs in 
tuberculosis, in infantile syphilis, and also as a result of acute or chronic 
disease of the stomach and intestines. Cases of wasting dependent upon 
such causes are not included in this chapter. 

Marasmus is the extreme form of malnutrition seen in infancy, occur- 
ring, so far as is now known, without constitutional or local organic dis- 
ease. It is a vice of nutrition only. 

Etiology. — Marasmus is not often seen in the country or in private 
practice. It is frequent in dispensary practice in all large cities, and is 
especially common in institutions for young infants. In my own experi- 
ence in four hospitals for infants, more than one half the deaths were 
directly or indirectly from this cause. Marasmus is a very large factor in 
the immense infant mortality of large cities in summer. Although the 
cause of death is usually reported under some other name, the determining 
factor in the fatal result is the previous marantic condition of the patient. 
The primary cause may be an inherent weakness of constitution which 
may depend upon heredity. It is often seen in premature children and 
in the illegitimate offspring of girls of sixteen or eighteen. In the vast 
majority of cases, however, it depends upon two factors — the food and the 
surroundings. Among the poor who live in tenements, infants who are 
artificially fed almost invariably do badly. This is due to ignorance in 
regard to the proper methods of infant-feeding and inability to procure 
what the child requires, especially pure cow's milk. A country infant 
may be neglected in many respects, and is often badly fed ; but it has 
plenty of pure air, and usually thrives. In the city, as long as an infant 
has a plentiful supply of good breast-milk it continues to do well in most 
instances, in spite of the fact that its surroundings are bad. When there 
are not only bad feeding and unhealthful surroundings, but also an in- 
herited constitutional vice, we have all the factors required to produce 
marasmus in its most marked form. The odds are so against the infant 
that its feeble spark of vitality nickers for a few months only and gradu- 
ally goes out. 

Another prominent factor in the production of marasmus is the over- 
crowding of infants in institutions. Even though artificially fed after the 
most approved methods, I have seen scores of infants who were plump 
and healthy on admission lose little by little, until at the end of three or 
four months they had become wasted to skeletons — hopeless cases of 
marasmus, dying of some mild acute illness, such as an attack of indiges- 
tion or bronchitis, the essential cause, however, being marasmus. The 
common mistake is that of placing too many children in one ward, with 



MARASMUS. 205 

no chance of obtaining a proper amount of fresh air. No house-plant is 
more delicate or sensitive to its surroundings than an infant during the 
first few months of life. 

Lesions. — The post-mortem findings in cases of marasmus are exceed- 
ingly unsatisfactory, and throw little if any light upon the disease. Every 
now and then general tuberculosis is discovered in patients dying appar- 
ently of marasmus, the existence of which was not previously suspected. 
In perhaps one third of the marked cases there is found a fatty liver. The 
organ is enlarged, often sufficiently so to be made out during life ; its 
weight may exceed the normal by one half, or it may be doubled in size. 
Both to the naked eye and under the microscope, it presents the usual 
changes of fatty degeneration, often to an extreme degree. The signifi- 
cance of this lesion I do not know. It is to be compared with the similar 
condition seen in tuberculosis and other chronic wasting diseases. It may 
be looked upon either as a cause or a result of the pathological process. 

With these exceptions the autopsies show nothing of importance, and 
I have had opportunity to make at least two hundred of them. The 
lesions usually found are the following : The brain is commonly anaemic, 
with dark fluid blood in the sinuses, marantic thrombi being rare. A strip 
of hypostatic pneumonia, usually about two inches wide, is seen along the 
posterior border of both lungs, involving the lung to the depth of half 
an inch, or less. In the younger infants there are frequently areas of 
atelectasis in the lower lobes. The pleura is almost invariably normal. 
The heart is pale, with perhaps a slight increase in the pericardial fluid. 
The spleen and kidneys are pale, but otherwise normal. The stomach 
may be dilated ; the mucous membrane is usually pale, often coated with 
tenacious mucus. The intestines contain undigested food, sometimes 
mucus. The solitary follicles of the colon and small intestine, and some- 
times Peyer's patches, are slightly enlarged, the mucous membrane in 
other respects being normal. The mesenteric glands are often slightly 
enlarged. In addition to the above, there may be evidence of some re- 
cent disease from which the patient has died— acute bronchitis, broncho- 
pneumonia, or a slight intestinal catarrh. 

The above lesions represent what has been found in the great majority 
of the cases, and very disappointing they are to one who sees them for the 
first time. Nor does the microscopical examination of the organs throw 
any light upon these cases. I have personally examined with care the 
stomach and intestines of more than a dozen cases, several of them in 
which autopsies were made only two or three hours after death, without 
finding anything of pathological importance. The theory advanced by 
certain German writers, that atrophy of the intestinal tubules is the ex- 
planation of marasmus, has found no support in my observations. 

The true pathology of marasmus seems to me to be a failure of assimi- 
lation from imperfect digestion, due to improper food, unhygienic sur- 



206 



NUTRITION. 



roundings, or feeble constitution. As a result, there is a progressive loss 
in weight, feeble circulation, imperfect lung expansion, imperfect oxida- 
tion of the blood, lowered body temperature, and, finally, a deterioration 
of the blood itself. Each of these effects becomes in turn a cause aggra- 
vating all the others, continuing until a condition is reached which is 







Fig. 31.— Marasmus; a patient in the Babies' Hospital, ten months old, weight six pounds. 
Weight at birth reported to have been nine pounds. 

incompatible with life, for resistance becomes so feeble that the slightest 
functional disturbance proves fatal. 

Symptoms. — The general history of these cases is strikingly uniform. 
The following is the story most frequently told at the hospital : " At birth 
the baby was plump and well nourished, and continued to thrive for a 
month or six weeks while the mother was nursing it ; at the end of that 
period, circumstances made weaning necessary. From that time the child 



MARASMUS. 20T 

ceased to thrive. It began to lose weight and strength, at first slowly, 
then rapidly, in spite of the fact that every known form of infant-food 
has been tried." As a last resort the child, wasted to a skeleton, is 
brought to the hospital. 

The most constant symptom is a steady loss in w T eight. The general 
appearance of these patients is characteristic. They have an old look ; 
the skin is wrinkled, has lost its tone, and hangs in folds upon the ex- 
tremities (Fig. 31). The legs are like drumsticks; the abdomen is promi- 
nent ; the temples are hollow ; the eyes large ; the features sharp ; and 
the hands resemble bird-claws. Often the children are reduced literally 
to skin and bone. Anaemia is a very marked and almost a constant symp- 
tom, the amount of haemoglobin being frequently reduced to 30 per cent., 
and in one case of mine to 18 per cent. Anaemic heart-murmurs are fre- 
quently heard. The body temperature is usually subnormal, unless arti- 
ficial heat is used. A rectal temperature of 9G° or 97° F. is very common, 
and one of 94° or 95° F. is occasionally seen. In addition to the pallor 
of the face, there may be a leaden hue due to congenital or acquired ate- 
lectasis. An occasional symptom is general oedema, depending upon the 
condition of the blood or blood-vessels. The first thing which calls at- 
tention to this is often an unexpected gain in weight. The oedema may 
increase until the cellular tissue of the whole body is affected. I have 
never, however, seen effusions into the large cavities. (Edema is usually 
associated with marked anaemia, and is generally a very bad symptom. 
The stools are sometimes normal, but usually contain undigested food, 
and are large in proportion to the amount of food taken. No matter how 
carefully fed, these patients are easily upset. Now and then mucus is 
seen in the discharges, but this is not a constant or a marked feature. 
Vomiting is excited from the slightest cause, and often food is regurgi- 
tated almost as soon as swallowed. The appetite, in a severe case, is almost 
entirely lost ; children refuse to take food from the bottle or spoon, and 
unless fed by gavage they die of inanition. In the earlier cases there may 
be an unnatural hunger, so that the children cry much of the time, and 
are relieved only when the bottle is given. 

The complications are thrush, erythema of the buttocks, and bed- 
sores, sometimes over the sacrum and heels, but most frequently upon the 
occiput. Occasionally there is seen a reflex spasm of the muscles of the 
neck, producing a marked opisthotonus, which may last for several days 
or weeks. 

The course of the disease in most cases is steadily downward. It may 
be cut short at any time by acute disease. Frequently these infants die 
suddenly when they have apparently been as well as for several weeks. In 
many instances the autopsy reveals no explanation of this sudden death ; 
but in other cases it is due to the regurgitation of food, and its aspiration 
into the larynx, the patient being too weak to cough. Rarely, death occurs 



208 



NUTRITION. 






from convulsions. In summer, these children wilt with the first days of 
very hot weather, and die often in a few hours from a slight functional 
derangement of the stomach and bowels. 

Diagnosis. — No sharp line can be diawn between marasmus and mal- 
nutrition. In the wasting which follows chronic disease of the stomach 
and intestines there is usually a history of an antecedent acute attack. 
The chief difficulty in the diagnosis of marasmus is to exclude tubercu- 
losis. In some cases a differential diagnosis is impossible during life. Not 
infrequently tuberculosis is found at autopsy, even in infants of a few 
months, in whom there have been no symptoms except those of maras- 
mus. Even when the signs in the lungs are present, if situated posteriorly, 
they may be due either to tuberculosis or to the hypostatic pneumonia 
which is present. Signs in front are more significant ; and consolidation 
anteriorly makes tuberculosis almost certain. In simple wasting there is 
often a history that the child was in splendid condition at birth, and con- 
tinued so until it was weaned, from which date it has gone down steadily. 
In tuberculosis no such definite cause may be present ; the children are 
often very delicate from birth. Simple wasting is so much more com- 
mon that the chances are always in its favour. 

Prognosis. — This depends on the age of the infant and the extent 
and duration of the disease. If the child is over eight months old, the 
chances of recovery are much better than in one under four months, for 
the fact that it has lived so long is generally evidence of pretty strong 
vitality. Very young infants are always difficult subjects to deal with. 
They go down more rapidly, and build up more slowly than those who 
are older. In most other circumstances the prognosis is much worse 
in cases of long duration. In a given case much depends upon whether 
-everything possible can be done for the child — whether a wet-nurse can 
be secured or artificial feeding done in the best manner, and whether the 
patient can have the benefit of the best surroundings, in the country in 
summer and a warm climate in winter where it can be kept out of doors 
the greater part of the time. In institutions cases under four months old 
are usually hopeless. Of those over eight months quite a proportion can 
be saved by proper treatment, even though the body-weight is reduced to 
-eight or nine pounds. When recovery occurs it may be complete, and 
the child at three years may be as vigorous as any child of its age. All 
these statements refer only to cases of simple marasmus. The presence 
of organic disease puts the case in another category. 

Treatment. — The most important is that which relates to prophylaxis. 
This, for large cities, may be summed up in a single sentence : giving the 
poor the opportunity to obtain pure cow's milk and teaching them how 
to feed it to young infants, and at the same time giving ample opportuni- 
ties for obtaining fresh air. In institutions the most important thing is 
to give adequate air-space for each child. Often only four or five hundred 






SCORBUTUS. 209 

cubic feet are allowed, when at least eight hundred are necessary, even 
with the best ventilation. Children should be changed from one apart- 
ment to another and opportunities given for thorough airing, and there 
should be perfect ventilation, not only in the daytime but at night. 

As far as possible, wet-nurses should be obtained if the infants are 
under four months old. For these very young patients success by artifi- 
cial feeding is not often possible. With those of six months and over, 
good artificial feeding is very frequently successful. In modifying cow's 
milk for these cases the formulas most likely to agree are those with low 
fat, low proteids — partly peptonized in many cases — and relatively high 
sugar. Such are obtained by formulas XV, XVI, and XVII, page 176. 
Starting with the lower percentages, they may be gradually increased to 
the highest ; then the fat may be increased to that in formula XIII. 
Further suggestions will be found in the chapter on Feeding in Difficult 
Cases (page 180). In institutions we are not likely to succeed very often 
without wet-nurses. 

For very young infants, with a temperature which is habitually sub- 
normal, the incubator should be used. If this is impossible, children 
should be rubbed with oil, rolled in cotton, and surrounded with hot- 
water bags or bottles. The general management should be much the same 
as described in the chapter on Malnutrition. At least once every day — by 
means of spanking, mild flagellation, or, better, by the alternate use of the 
hot and cold baths — children should be made to cry vigorously, in order 
to keep the lungs expanded. They require no drugs, but a great deal of 
careful nursing. 



CHAPTER VI. 
DISEASES DUE TO FAULTY NUTRITION. 

The diseases due to faulty nutrition are really numerous. There are, 
however, two which have been so clearly shown to originate in this way 
that they may be singled out and put in a class by themselves. These 
are scorbutus and rickets. The prevailing opinion of the medical pro- 
fession is that both of these are essentially " food-diseases." The purpose 
of considering them in connection with the disturbances of nutrition is 
to emphasize this relationship. 

SCORBUTUS (SCURVY). 

Scorbutus is a constitutional disease, due to some prolonged error in 

diet. It is characterized by spongy, bleeding gums, swellings and ecchy- 

moses about the joints, especially the knee and ankle, hasmorrhages from 

the nose, and occasionally from other mucous membranes, extreme hyper- 

18 



210 NUTRITION. 

sesthesia, and often pseudo-paralysis of the lower extremities. Added to 
these local symptoms there is usually a general cachexia with marked 
angemia. While scorbutus and rickets are very frequently associated, they 
are not necessarily connected, and can hardly be considered as different 
forms of the same disease ; although cases of scorbutus have been described 
in older writings under the title of Acute Eickets. The course of the 
disease is somewhat chronic, lasting for weeks or months ; and while it 
usually yields immediately to proper treatment, if unrecognised and if the 
original error in diet is continued, it not infrequently proves fatal. It is 
only within the last twelve or fourteen years that infantile scurvy has 
found a distinct place in medical literature. For our present understand- 
ing of the disease, the profession is indebted chiefly to the work of the 
English physicians Cheadle, Gee, and Barlow, especially the last named, 
who in 1883 made a full report upon thirty-one cases of scorbutus in in- 
fants and young children, in which publication the etiological factors and 
clinical history were worked out so fully that but little has since been 
added to the subject. In Germany it still passes to-day under the title of 
Barlow's Disease. To Northrup is due the credit of bringing the subject 
prominently before the minds of the profession of this country.* 

Etiology. — Scorbutus is not uncommon in infancy, but it is frequently 
unrecognized. During the past two years twelve cases have come under 
my own observation. All of these were under two years of age, as were 
also all of Cheadle's twenty cases and twenty-five of Barlow's original 
thirty-one. The great majority of cases occur between the eighth and 
twentieth months. There is no preference for sex or season. Since the 
essential cause of scorbutus is dietetic, it may be found in all surround- 
ings. Of the reported cases, the majority have occurred in private prac- 
tice and among the better classes of society, in the country quite as often 
as in the city. The previous diet of most of the patients who develop 
scurvy has been either some of the proprietary foods or condensed milk, 
or a combination of the two. Scurvy may be induced by the giving of 
proprietary foods, even when a small amount of cow's milk has been 
added. In one reported case (Delafield's), scurvy was produced in a child 
three years old by an exclusive diet of rare meat, continued for three 
months. 

Since the introduction of the practice of heating milk used in infant- 
feeding, the question has been raised in many quarters whether this may 
not be a cause of scurvy. I have carefully investigated this question in 
the records of three institutions in which for five years " sterilized " milk 
has been the standard food for all artificially- fed infants. The number of 
children under eighteen months who have had this diet is nearly one 



* See paper by Northrup and Crandall, New York Medical Journal, May 26, 1894, 
in which will be found thirty-six tabulated cases. 



SCORBUTUS. 211 

thousand. During this period but two cases of scurvy were observed, 
and in neither case had the child been upon a diet of " sterilized " milk. 
However, I have recently seen in private practice two cases of scurvy in 
which the cause seemed to be prolonged sterilization at a high temperature 
— i. e., 212° F. for over an hour. In some of the cases in which the "ster- 
ilized" milk is supposed to have been the cause of scurvy, it is undoubt- 
edly the milk-formula employed which was at fault, and not the process 
of heating. In two patients under personal observation, who developed 
scurvy while taking " sterilized " milk and a proprietary food, the food 
was discontinued and the patient recovered, although heating the milk 
was continued. In four cases observed by Winters no other treatment 
was employed than the substitution of " sterilized " milk for the previous 
diet, which in three instances had been proprietary foods. All the patients 
j)romptly recovered. In these cases the milk was heated to 212° F. 

Scurvy in nursing infants is very rare. In one of Northrup's cases, a 
fatal one, the foundling was wet-nursed by a woman whose own child 
thrived. The presumption here was that the scurvy was induced by in- 
sufficient food. Southgate* has reported a fairly typical case of scurvy in 
an infant of fifteen months, who had been nursed exclusively up to that 
time. The child was rachitic and quite markedly cachectic, but recovered 
immediately when weaned and placed upon a diet of cow's milk, orange- 
juice, potato, etc. The probabilities are that in this case the scurvy was 
due to the poor quality of the breast-milk, coupled with the bad surround- 
ings of the child. 

From all the above evidence it would appear that scurvy may be in- 
duced by the continued use of any food which either lacks some elements 
needed for the child's nutrition, or which furnishes them in such a form 
that the child can not assimilate them. Clinical experience is overwhelm- 
ing in support of the view that it is the proprietary infant-foods which 
are most certain to produce scurvy, especially when they form the exclu- 
sive diet. 

Symptoms. — The following cases illustrate the chief clinical types of 
the disease : 

The most serious form with fatal termination. — A case of extreme 
marasmus came under observation in the Babies' Hospital, in 1892, in an 
infant who for two months had been upon an exclusive diet of a well- 
known proprietary food. At the end of that time there was observed a 
swelling about the left knee, which slowly increased in size, and was ac- 
companied by an extreme degree of tenderness about the joint. The 
swelling was diffuse, spindle-shaped, and accompanied by a purplish dis- 
coloration of the skin. A little later the gums became spongy and bled 
easily at the margin of the teeth. In places where the next teeth were 

* Archives of Puecliatrics, vol. xi, p. 505. 



212 NUTRITION. 

expected, the gum was purple aud swollen, evidently from submucous 
ecchymoses. There were very marked cachexia and anaemia. The swell- 
ing extended up to the middle of the thigh, and gradually increased in 
size until the limb was fully four inches in diameter. An aspirating 
needle was introduced, but only blood was found. The child wasted 
steadily, and died of exhaustion two months after the appearance of the 
first symptoms. During the last few weeks slight fever was present. 

The autopsy in this case showed the typical lesions of scorbutus. The 
periosteum of the femur was stripped from the bone throughout the lower 
two thirds of its extent by subperiosteal hemorrhage. There were also 
extravasations of blood between the muscles and into the subcutaneous 
tissue, and to these haemorrhages the swelling was mainly due. There 
was complete separation of the lower epiphysis from the shaft. No other 
bones were aifected. 

In most of the cases, however, that have come to autopsy other bones 
also have been involved with lesions of a similar character ; the other long 
bones most frequently affected are the tibia and humerus ; of the flat 
bones, the scapulae and cranium. Epiphyseal separation may take place 
near any of the large joints, haemorrhages may be found between the 
muscles, in the subcutaneous tissue, and occasionally in the lungs, spleen, 
and kidney. The lesion in the mouth is a haemorrhagic gingivitis. 

A typical case of the severe form, ending in recovery. — The patient 
was a boy fourteen months old, of healthy parents and good surroundings, 
living in a country town near New York. At birth it was said he weighed 
fourteen pounds. The mother being unable to nurse him, he had been fed 
exclusively upon condensed milk and proprietary foods. He had never 
thriven, but the symptoms of malnutrition and anaemia had been the only 
ones present until four months before comiug under observation. The 
evolution of the symptoms in this case is interesting because it is so typical. 
There was first noticed tenderness about the ankles, then about the knees, 
this being so acute that the child screamed whenever the limbs were 
handled, but at other times he gave no evidence of pain. A little later, 
boggy swellings were discovered about one knee and both ankles. Soon 
after this the gums were noticed to bleed frequently, and at times they 
were so much swollen as to conceal the teeth. All these symptoms had 
continued up to the time the child was brought for treatment. He had 
been growing gradually worse, each day becoming more anaemic and ca- 
chectic. Several attacks of epistaxis had occurred, and once there had 
been haemorrhage from the ear. In one of the best general hospitals of 
New York the diagnosis of ostitis of the knee had been made, and a 
plaster-of- Paris splint applied. 

On examination, the child presented the signs of rickets of moderate 
severity. There were irregular swellings about the left knee and ankle, 
but no discoloration of the skin. Slight swelling was seen also upon the 



SCORBUTUS. 213 

lower part of the right leg. The limbs were exquisitely tender, the slightest 
movement causing the child to scream with pain. It was several months 
since voluntary movement had been seen, and the legs now lay absolutely 
motionless, apparently owing to the pain which any attempt at motion 
excited. The gums were like those in the preceding case, but the condi- 
tion was more marked, and ulceration was seen along the incisor teeth. 

Under treatment exclusively dietetic, the symptoms, which had been 
unchanged for three months, were wonderfully improved in three days ; 
and at the end of two weeks the child was kicking his legs about, the 
swelling and tenderness were gone, the gums entirely well, and the gen- 
eral condition greatly improved. The case went on to a rapid and com- 
plete recovery. 

The mildest type seen without either swellings or mouth-symptoms. — 
These cases are not often recognised as scurvy, but they are probably the 
most common form. This child was seen in the country, in private prac- 
tice. It was an exceedingly healthy infant in appearance, nine months 
old ; the diet from birth had been milk " sterilized " at 170°, with the 
addition of a well-known infant-food. At the time of his attack he was 
apparently in the best of health, with bright red cheeks. He was first 
noticed to cry out sharply as if in pain when lifted in a certain way. It 
soon became evident that the trouble was located about the left knee. 
Nothing could be discovered upon examination except a very great amount 
of tenderness. This symptom continued for six weeks ; on some days the 
tenderness was extremely acute, and on others scarcely noticeable. After 
three weeks a slight ecchymosis was discovered over the head of the tibia 
of the affected limb. About this time tenderness and a disinclination to 
move the right shoulder were noticed, and soon an ecchymosis like a small 
bruise was seen in front of the shoulder joint. The diet at this time was 
a liberal amount of milk, a small quantity of the infant-food daily, with 
beef juice. The ecchymoses about the knee and shoulder, with tender- 
ness, pain, and disability, sufficed for a diagnosis of scurvy, in spite of the 
fact that the gums were normal, although two teeth were through, and 
that no swelling existed about the joints. The proprietary food was now 
discontinued, the amount of beef juice increased, and in three days the 
symptoms entirely disappeared. No change in heating the milk was made. 

I have seen several other cases presenting symptoms in all respects 
identical with the above, but lacking even the ecchymoses about the joints, 
which were immediately relieved by dietetic treatment after having lasted 
from two to six weeks. In none of these cases were the gums affected, 
but in one there was quite a marked cachexia. There is no doubt in my 
mind that all these were cases of genuine scurvy of a mild type, and if 
allowed to go on would have developed the other usual symptoms. 

In older children, scurvy is occasionally seen with causes and symp- 
toms more like the adult type of the disease. The symptoms referred to 



214 NUTRITION. 

the lower extremities are not so marked. There are swelling and spongi- 
ness of the gums with frequent haemorrhages ; the teeth may loosen and 
fall out ; there may even be some sloughing of the gums ; the breath is 
intensely fetid ; and haemorrhages may take place from the kidneys, the 
bladder, or the stomach. There is a very marked general cachexia, ex- 
treme languor, and often syncopal attacks. These cases are usually due 
to a diet deficient in fresh vegetables, and are most frequent among the 
very poor. 

Diagnosis. — The diagnosis of scorbutus is usually an easy one, as the 
great majority of cases are fairly typical. The symptoms to be relied 
upon for diagnosis are : 

1. Hyperaesthesia, especially about the knees and legs, which is often 
very acute. It may be the first symptom noticed. The pain is increased 
by any motion or pressure, but otherwise does not seem to be present. 

2. There is disability or disinclination to move the limbs — usually the 
legs — which may be so great as to lead to the suspicion of paralysis. This 
disability is usually due to pain, sometimes to epiphyseal separation. It 
is similar to the pseudo-paralysis of hereditary syphilis depending upon 
osteo-chondritis. 

3. The mouth is the seat of haemorrhagic gingivitis. The gums are 
swollen, bleed easily, and at times cover the teeth. There is ulceration 
about the teeth which have appeared, and partial discoloration of the 
mucous membrane over the teeth soon to appear. 

4. There are swelling and ecchymoses about the large joints, especially 
about the knee and ankle. The ecchymoses may be seen in any part of 
the body. 

5. There may be haemorrhages from the mouth, nose, stomach, bowels, 
and occasionally from the kidneys. In rare instances haemorrhage has 
been the most prominent symptom. 

6. There are a general cachexia and marked anaemia with flabby mus- 
cles, and often the signs of rickets. 

7. There is a history of bad feeding, usually of the continued use of 
some proprietary food. 

8. The symptoms are immediately improved and in most instances 
rapidly cured, by antiscorbutic diet without other treatment. This is 
perhaps the most diagnostic of all the symptoms. 

Scorbutus in infancy is usually mistaken for rheumatism or paralysis ; 
less frequently for rickets, ostitis, and purpura. By close attention to the 
symptoms above mentioned it is almost impossible to make a mistake in 
diagnosis. 

Prognosis. — This is invariably good if the disease is recognised early. 
Scarcely any other cases improve with such marvellous rapidity as do 
these when the proper dietetic changes are made. Complete recovery can 
usually be predicted in two or three weeks. Death is not an uncommon 



RICKETS. 215 

termination in cases which have been unrecognized. Of Barlow's thirty- 
one cases seven were fatal. I have seen but one fatal case. 

Treatment. — This is remarkably simple : to discontinue all propri- 
etary foods and condensed milk, and give an abundance of fresh cow's 
milk, beef juice, orange juice or other fresh fruit, and, in cases that are 
over a year old, potato. In addition, iron and cod-liver oil may be re- 
quired later, but the essential thing is the change in diet. 

The tenderness requires that the child shall be kept as quiet as pos- 
sible, and its cachexia that it be protected against cold and exposure. 

RICKETS (RACHITIS). 

Rickets is a chronic disease of nutrition. While the only important 
anatomical changes are found in the bones, it is not to be regarded as a 
bone disease ; but as a very complex pathological process which affects the 
bones, muscles, ligaments, mucous membranes, and nearly all the organs 
of the body, particularly those of the nervous system. It occurs especially 
between the ages of six months and two years. It is not common in the 
country, but is exceedingly frequent in most large cities. While not a 
fatal disease per se, rickets adds very greatly to the danger from all acute 
diseases in infancy, and even to some degree also to those of later life. 
Under proper conditions of diet and hygiene it tends to spontaneous 
recovery. 

Etiology. — The essential cause of rickets is dietetic, although hygienic 
influences play a very important role in its production. While it seems 
to be demonstrated that diet alone may produce rickets, nevertheless this 
condition is much more easily produced when there are also unfavourable 
hygienic surroundings. Rickets is not common in nursing children un- 
less lactation be unduly prolonged,* as, for example, where nursing is 
continued for fifteen to eighteen months without other food. Arti- 
ficially-fed children are much more prone to the disease, especially those 
who are badly fed. The diet in these cases is usually very deficient in fat, 
and often at the same time in proteids, while it contains an excess of car- 
bohydrates. It is somewhat difficult to separate the effects which these 
different conditions produce. It appears, however, that the most impor- 
tant factor is a great deficiency in fat. Rickets is exceedingly common in 
children reared upon the proprietary foods, nearly all of which are very 
low in fat and contain an excess of carbohydrates. It is also common in 
children who are reared upon sweetened condensed milk, and for precisely 
the same reason. When both fat and proteids are low, rickets is more 
liable to result than when only the fat is deficient. 

* An exception to this statement must be made in the case of Italian children. In 
this class as observed in New York it is very common to see marked rickets in those 
getting nothing but the breast. 



216 NUTRITION. 

Hygienic surroundings are next in importance to diet. Although, as 
previously stated, rickets is essentially a disease of cities, being princi- 
pally seen in children living in crowded tenements where the effects of 
improper food are most strikingly shown, yet even here the disease is rare 
in those who get a plentiful supply of good breast milk. 

Animal experiments. — Bland-Sutton experimented, in the Zoological 
Gardens, London, upon lion whelps. Those which were weaned early and 
fed solely upon raw meat invariably became extremely rachitic. Two 
young cubs, fed upon rice, biscuits, and raw meat, died from rickets. 
Two young monkeys, upon an exclusively vegetable diet, became rachitic. 
To the young lions who had developed rickets, milk, cod-liver oil, and 
pounded bones were given in addition to the meat, and in three months, 
although the hygienic condition of the. animals remained unchanged, all 
signs of rickets had disappeared. Guerin produced typical rickets in 
puppies which were kept upon a meat diet for four or five months, while 
others of the same litter, which were suckled, remained in good health. 
Other animal experiments by various observers with different articles of 
food have given results that were not uniform. It seems, however, to be 
pretty positively established, that withholding milk from young animals 
and putting them upon a diet of meat, vegetables, or starches is sufficient 
to produce rickets, and that the earlier this is done the more certain is 
the result. This may occur apart from any change in the hygienic sur- 
roundings. These animal experiments strengthen the opinion above 
given, that the essential cause of rickets is improper food, and that the 
element most uniformly lacking is fat. 

Distribution of rickets. — According to Palm, the disease is almost un- 
known in the extreme north — Greenland, Iceland, Norway, and Den- 
mark. It is also very rare in China, Japan, Greece, Turkey, and the 
southern portions of Italy and Spain. Its greatest frequency is in the 
temperate zone. The general immunity of children in southern climates 
appears to be due to the out-of-door life, and the almost universal custom 
of maternal nursing. In the cities of America no race is exempt from 
the disease. In New York the greatest susceptibility is among the Negroes 
and the Italians. Extreme cases of rickets are almost invariably in one 
of these nationalities. It is exceptional to see in a dispensary or hospital 
a child of either of these races who does not show, to a greater or less 
degree, the signs of rickets. These two southern races seem to bear very 
badly the climate and the confined life of the northern cities. So far as 
my observations are concerned, there is no peculiarity in the food of these 
people which explains the prevalence of rickets among them, and this 
must be attributed to a race peculiarity. In the country, the immunity 
from rickets is due partly to the more prevalent custom of maternal nurs- 
ing, and partly to the better surroundings ; the increased resistance of the 
children rendering them much less susceptible to the influences of bad 



RICKETS. 217 

feeding than those of the cities. In Kew York among dispensary and 
hospital patients, rickets is exceedingly common, and is seen in all nation- 
alities, although chiefly in the foreign elements of the population. 

Heredity. — There is no evidence that rickets is a hereditary disease. 
Any cachexia in the parents, such as syphilis, tuberculosis, or alcoholism, 
may, however, by diminishing the child's resistance, be a predisposing 
cause of rickets. The later children in a family are more likely to be 
affected than the earlier ones, especially when the intervals between the 
pregnancies has been short, or where anything else has caused a deterio- 
ration in the general health of the mother. 

Previous disease. — Eickets not infrequently develops in syphilitic 
children ; the connection, however, seems to be no closer than to any 
other cachexia. The relation of rickets to other diseases, particularly 
with those of the digestive tract, is very much less intimate than one 
would expect. Acute diseases of the stomach and intestines are very 
frequently followed by marasmus, but only exceptionally by marked 
rickets. There is no sufficient ground for believing that rickets exerts 
any protective influence against tuberculosis, as has been asserted. In 
fact the thoracic deformity of rickets may be a predisposing cause to that 
disease. 

Rickets affects both sexes with equal frequency. The symptoms usu- 
ally manifest themselves between the sixth and fifteenth months. Con- 
genital and late rickets will be considered separately. 

Rickets is therefore a complex disease of nutrition, whose exact 
pathology has not yet been definitely settled. It is more difficult to 
believe that the general nutritive disturbances are the result of the bone 
changes, than to regard both as having a common origin. Kassowitz 
regards the bone changes as inflammatory, excited by the presence of 
some irritant. The irritant has been believed by many to be lactic acid, 
originating in the digestive tract ; but the evidence in support of this 
theory is not conclusive. It is very doubtful whether the process is as 
simple as the formation of lactic acid in the intestine and its circulation in 
the blood. It is, however, clear that it is something which interferes with 
the assimilation of the lime salts. At the present time, the disposition is to 
regard rickets as a disease of nutrition, which may be produced in animals 
by certain dietetic changes. In infants, it seems to be settled that it may 
be produced by similar changes in diet, aided very greatly, however, by 
unhygienic surroundings. The effect of these abnormal conditions is 
shown upon the whole organism, but the only constant and regular ana- 
tomical changes are in the bones. These osseous lesions resemble those 
of chronic inflammation. Precisely how the dietetic and other causes 
produce the bone changes is still a matter of speculation. The constancy 
of bone changes in rickets give it a place as an essential disease, and not 
merely a form of malnutrition. 
19 



I 



218 NUTRITION. 

Lesions. — The only constant and characteristic lesions of rickets are 
found in the bones. It is still a matter of dispute whether these bony 
changes are to be considered as inflammatory, or simply as the result of 
disordered nutrition. Perverted nutrition and chronic inflammation are 
closely allied, and it really makes but little difference which view is taken. 
Occurring at a time when the growth of bone is so rapid, the effects of 
rickets are very striking and very serious. 

In order to appreciate how bones are affected by rickets, it must be re- 
membered that the long bones grow in length by the production of bone 
in the cartilage between the epiphysis and the shaft ; that the shaft grows 
in thickness by the production of bone beneath the inner layer of the 
periosteum ; and that the medullary canal is continually increasing in 
size by the absorption of the inner layers of the bone. In rickets there is 
an exaggerated production of cartilage at the epiphysis, and excessive cell- 
growth beneath the periosteum, while the process of ossification in these 
tissues goes forward slowly and imperfectly, or is entirely arrested. At 
the same time the absorption of the medullary layers may be even more 
rapid than normal. In health the growth of bone in length is much 
more rapid than its increase in diameter, owing to the greater activity of 
the changes taking place at the epiphysis; sb, in rickets, it is at the 
extremities of the long bones that the most marked changes are seen. 

One of the most striking features of rachitic bones is their unnatural 
flexibility. This is due to deficient ossification in the superficial layers of 
the shaft of the long bones, and also at their extremities. Normally, 
bone contains about one third organic and two thirds inorganic matter. 
In marked rickets the proportions are reversed, the bones often containing 
twice as much organic as inorganic matter. Changes are seen in all the 
long bones, but all are not affected to the same degree. Sometimes those 
most affected will be the bones of the leg, sometimes those of the forearm, 
and sometimes the ribs. The extent varies with the severity of the process. 

There are characteristic changes in form. The most constant is en- 
largement of the epiphyses of all the long bones. This is most strikingly 
seen in the lower extremities of the radius and tibia. The enlargement 
may be so marked that the width of the epiphysis is increased by one half 
its diameter. All the sharp angles, borders, and prominences of the bones 
are rounded off. The curvatures of rachitic bones are more fully de- 
scribed under the symptoms. They may be due to a variety of causes. 
Some are simply an exaggeration of the normal curves, much increased 
by the swelling of the epiphyses ; others are due to muscular action, to 
atmospheric pressure, to some unnatural posture, such as the cross-legged 
position, to the weight of the limbs, or to the weight of the body. The 
principal change in the form of the flat bones consists in the production 
of large bosses or prominences due to thickening of the bone, usually 
about the centre of ossification. These bosses are soft and spongy. Frac- 



PLATE IV. 



h 




i-d 



--D 



Bone in Rickets. 

Longitudinal section of a rib at the junction of the costal cartilage, in a severe 
case of rickets (slightly magnified). C = costal cartilage, B = bone, A = proliferating 
cartilage-zone, which is much widened. Between the hypertrophied cartilage cell- 
columns (a) making up this proliferating zone, are seen medullary spaces (b) contain- 
ing blood-vessels. In this zone lie masses of bone (c) not calcified'. The calcification 
zone is almost wanting, only scattered islands (d) of calcified cartilage-cells being seen. 

Beyond this proliferating zone (A) is a layer of bony tissue (B) made up of small 
bands of which only a few have a nucleus containing lime (e). These nuclei appear 
black. The bony bands differ both in form and arrangement from those of normal 
ossification. Between the bony masses are medullary spaces which appear light in the 
illustration. At (g) the beginning of cartilage proliferation is seen. Above this zone 
the cartilage is normal. (From Karg and Schmorl.) 



RICKETS. 219 

tures are not uncommon. The bones most frequently broken are the 
radius and ulna ; next, the clavicle or the ribs. The fractures are usually 
of the green-stick variety. There is a bending of the outer and a frac- 
ture of the inner layers of the shaft of a long bone. This results in more 
or less impaction, and is usually followed by the production of consider- 
able callus. The epiphyseal changes result in arrested growth in length, 
rachitic bones being usually much shorter than normal. Increased vascu- 
larity is seen in the bosses upon the flat bones, at the extremities of the 
long bones and upon stripping the periosteum from the shaft. 

In a longitudinal section of one of the long bones, the principal change 
seen at the extremity is that the cartilaginous layer which unites the epi- 
physis and the shaft is very much enlarged, both in width and thickness, 
the latter being sometimes four or five times the normal. This cartilagi- 
nous area is of a bluish colour, rather softer than normal cartilage. On one 
side it blends with the cartilage of the epiphysis, on the other it presents 
an irregular dentated border, and in it the calcified areas are irregular and 
scattered. The epiphyseal centres of ossification are enlarged, softer, and 
more vascular than normal, thus increasing the size of the extremity of 
the bone. In the shaft, the outer layers of bone are thickened and soft, 
like decalcified bone, the deeper parts being firmer, while the deepest 
layers may be completely ossified. The medullary canal is much more vas- 
cular than normal, its contents resembling granulation tissue. Toward 
the extremities the trabecular spaces are much increased in size, so that 
the bone appears unnaturally porous. On vertical section of one of the 
flat bones — e. g., one of the bosses upon the skull — there is found a great 
increase in the size of the trabecular spaces. The bosses are made up of 
large spongy masses, so soft as to be easily indented with the finger, and 
on pressure there oozes blood and serum in a considerable quantity. 

Microscopical changes. — At the junction of bone and cartilage at the 
extremity of one of the long bones, there are readily traced in normal 
bone (Fig. 32) several distinct zones. Next to the hyaline cartilage (a) 
there is a proliferating zone (#), made up of cartilage cells and matrix, 
the cells having no orderly arrangement. Next to this is a columnar 
zone (c, d), in which the cartilage cells are arranged in regular rows or 
columns. Adjoining this is the zone of calcification (e) ; and, finally, there 
is the zone of ossification (/, //), where true bone is formed. 

In rickets (Plate IV and Fig. 33), the principal changes are seen in the 
proliferating and columnar zones. The proliferating zone (Fig. 33, b) is 
increased chiefly by the multiplication of new cells ; it is also more vas- 
cular than normal. The columnar zone (c) is affected in a similar way 
and to a much greater degree. It is less regular in its formation, and, 
instead of containing but few vessels, it shows large vascular channels, 
sometimes surrounded by medullary spaces (e). The ossification zone, 
instead of being narrow and sharply outlined, is broad and very irregular. 



220 



NUTRITION. 



Calcified areas (/) may be seen in the midst of regions which are carti- 
laginous, while masses of cartilage (A) occupy areas which should be com- 
pletely calcified. In some places there appears to be a transformation of 
cartilage into bone-tissue of an inferior sort by a direct or metaplastic 
process. In the shaft there is seen more or less thickening, and au in- 
creased vascularity of the periosteum. Beneath the inner layer there is 






B b§ 



■H ■ 




Fig. 32.— Section through ossification zone of normal bone (Ziegler). a, hyaline cartilage; 6, 
zone of beginning cartilage proliferation ; c, columns of cartilage cells ; d, columns of hyper- 
trophic cartilage ; <?, zone of temporary calcification ; f, zone of primary medullary spaces ; 
#, zone of primary bone formation ; A, fully developed spongy bone ; *, blood-vessels ; &, 
layer of osteoblasts. 



excessive cell-proliferation, while calcification of this new tissue is imper- 
fect or absent, and instead of hard, compact bone, we find irregular, spongy 
masses. In the spongy bone there is considerable thickening, with an 
erosion of bony trabecule, which results in the formation of large medul- 
lary spaces filled with blood-vessels and connective tissue rich in cells. 



RICKETS. 



221 



Termination of the rachitic process. — After a variable time, usually 
from three to fifteen months, the active proliferative process going on in 
the cartilage and beneath the periosteum ceases, and is gradually replaced 




Fig. -°».3. — Rachitic bone (Ziehen. Longitudinal section through ossification zone of the upper 
diaphysis of the femur of a moderately rachitic child one year old (highly magnified i. a. 
unchanged hyaline cartilage ; ^beginning cartilage proliferation; c, columns of proliferated 
cartilage cells ; d, columns of proliferated hypertrophic cells: e. medullary spaces contain- 
ing blood-vessels lying within the cartilage \f. calcified cartilage; g, bony tissue: ^re- 
mains of cartilage within the bony tissue; i, point of uncalcified bony tissue; /•, calcified 
bony tissue. 



by ossification. The bone becomes less vascular, and a rapid formation 
of bone takes place in the normal way. In addition, there is in some 
places a direct transformation of cartilage into bone. Condensation and 



222 NUTRITION. 

contraction take place in the spongy masses of bone. As the result of 
this, the affected bone may become even harder than normal ; often it is 
ivory-like. Its structure, however, is never quite like that of healthy bone. 

In the long bones the epiphyseal swellings slowly diminish, and may 
quite disappear; the slighter curvatures may be entirely overcome, and 
the greater ones much lessened. The beading of the ribs becomes almost 
imperceptible ; the bosses upon the skull shrink very markedly, and may 
leave scarcely a trace of their existence. In most cases the active process 
in rickets has come to an end by the time the child is two and a half years 
old, often at two years. 

Visceral lesions. — These are not infrequent, but are not essential to 
rickets. In the lungs they are due to deformities of the chest wall and 
to complications. Beneath the deep lateral furrows which are so common, 
there is found a part of the lung in a state of more or less complete col- 
lapse. This is accompanied by emphysema of the portion just anterior to 
it. Acute and chronic bronchitis and broncho-pneumonia are exceed- 
ingly frequent. A low grade of chronic catarrhal inflammation in the 
stomach and intestines is common, and is often associated with dilatation 
of these organs. The spleen is enlarged in most cases during the period 
of active symptoms. This is usually moderate in degree, although marked 
enlargement is sometimes met with. The swelling of the spleen is due 
to simple hyperplasia, and not to amyloid degeneration. Enlargement 
of the liver is less frequent, and may occur with or without that of 
the spleen. There are no constant changes in the structure of these 
organs. The lymph nodes (lymphatic glands) are frequently enlarged. 
Eachitic patients are more prone to these swellings than are other chil- 
dren. They are due to simple hyperplasia, and have no close connection 
with rickets. Cerebral changes are rare, and those described are rather 
of accidental occurrence than dependent upon the rachitic process. As 
stated under Symptoms, enlargement of the head is usually due to thick- 
ening of the cranial bones. Although hydrocephalus is occasionally seen, 
it is extremely doubtful whether it is more frequent than in patients not 
rachitic. Hypertrophy of the brain has been described in connection 
with rickets, but as yet this does not seem to be established by sufficient 
pathological evidence. The muscles are flabby from imperfect nutrition, 
and sometimes atrophied from disuse, but no essential anatomical changes 
have been demonstrated in them. 

Symptoms. — A well-marked case of rickets makes a striking picture 
(Plate V), and one not easily mistaken. There are seen the large head, 
beaded ribs, narrow chest, prominent abdomen, symmetrical swellings of 
the epiphyses of the wrists and ankles, and curvatures of the extremities. 
The beginning of symptoms is nearly always insidious, and the patient 
does not usually come under observation until they have existed for sev- 
eral weeks, often several months. 



PLATE V. 




Typical Rickets. 

Showing the large head, narrow chest 
of the epiphyses at the wrists and ankles, 
and legs which are not so well shown. 

The patient a child two and a half years old. 



prominent abdomen, marked enlargement 
There are also curvatures of the forearms 



RICKETS. 223 

Early Symptoms. — The most constant early symptoms are sweating 
of the head, extreme restlessness at night, constipation, beading of the 
ribs, and cranio-tabes. The head-sweating is rarely absent, and may con- 
tinue for several months. It is especially profuse during sleep, the per- 
spiration standing out in large drops upon the forehead, often being 
sufficient to wet the pillow. This is one of the causes of the nasal and 
bronchial catarrhs so common in rachitic infants. There is marked rest- 
lessness during sleep : the children tossing about the crib, kicking off the 
clothes, and never having the quiet, natural slumber of healthy infants. 
This may be due to many causes, but when persistent and associated with 
marked perspiration of the head, rickets should be suspected. Constipa- 
tion is frequently seen as an early symptom, although it is more marked 
in the later stages of the disease. 

The beading of the ribs is almost invariably the first appreciable 
change in the bones, and it is well-nigh constant. This forms the so- 
called " rachitic rosary," consisting of nodules at the line of junction of 
the costal cartilages and the ribs. It may be slight, or there may be a 
row of knobs as large as small marbles. In many cases with marked 
thoracic deformity, little or no beading of the ribs is seen externally, 
although at autopsy it is found to be very marked upon the internal sur- 
face of the chest (Plate VI). Beading of the ribs was noted in all but 
two of one hundred and forty-four successive cases of rickets, at the time 
of the first examination. In infants under six months there may be 
found soft spots in the cranium, usually over the occipital or posterior 
portions of the parietal bones. These are from one fourth to one inch in 
diameter, and there are usually several of them present. By pressure with 
the finger they give a sort of parchment-crackling sensation. They are 
known as cranio-tabes. In my own experience this has not been a fre- 
quent symptom. Cranio-tabes is more frequently seen when syphilis is 
associated with rickets, and it is seen also in syphilitic cases which are not 
rachitic. The rachitic cachexia is not usually present until the symptoms 
have existed for several months, and in many cases it is not seen at all. 

Deformities. — The deformities of rickets are almost invariably sym- 
metrical in character, and usually numerous. In extreme cases almost 
every bone in the body is affected. 

Head : This usually appears to be too large, and although it may 
not be greater in circumference than that of a healthy child of the same 
age, it is out of proportion to the rest of the body. In marked cases 
the increase in circumference may be nearly two inches. The enlargement 
is mainly or solely due to thickening of the cranial bones. In one case 
with marked deformity, I found the skull over the parietal bones half an 
inch in thickness (Fig. 34). This thickening diminishes with recovery, 
but in most cases the head remains throughout life larger than it should 
be. The shape of the rachitic head is somewhat square (Fig. 35), owing 



224 



NUTRITION. 



to the formation of large bosses over the parietal and frontal eminences. 
It is flattened at the occiput from pressure, and flattened also at the ver- 
tex. In extreme cases, the prominences upon the frontal and parietal 
bones may be so great as to produce quite a marked furrow along the line 
of the sagittal and frontal sutures, and one at right angles to this along 
the coronal suture (Fig. 36). This condition gives unusual prominence 
to the forehead. Marked deformity of the head has been observed in 
thirty-three per cent of my cases. The sutures may remain open for an 



Wm 


w^^^ 




■ 


^ 


1 


W A 












1 


M^ r h 














5 


mmM^^S 




"""""^l 



Fig. 34.— Rachitic skull from colored child two years old, horizontal section, inner surface; 
showing thickening of the bones, especially the frontal, and open fontanel. 



unnatural time, occasionally until the end of the first year. The fontanel 
is late in closing, being frequently found open at two and a half, and 
sometimes even at three years. Often at eighteen or twenty months 
the fontanel is two inches in diameter. The veins of the scalp are 
often prominent, and the hair is frequently worn from the occiput, 
owing to restlessness during sleep. Occasionally rickets and hydrocepha- 
lus are associated, but this is the least frequent of all causes of enlarge- 
ment of the head. 



PLATE VI. 





Deformity of the Chest in Severe Rickets. 

In the upper picture, giving the external view, is shown a deep oblique furrow at 
the junction of the ribs and costal cartilages, these meeting at an acute angle. 

In the lower picture the ribs have been separated from the spine and spread open, 
showing the same deformity as it appears from within, looking forwards. 

From a coloured child ten months old. 



RICKETS. 



225 



Chest : Beading of the ribs has already been mentioned. This is the 
most characteristic feature, but in the majority of cases there are, in 
addition, lateral depressions over 
the lower third of the chest, at 
the line of junction of the car- 
tilages with the ribs, with ever- 
sion of the lower borders of the 
ribs. In severe cases these de- 
pressions or furrows are so great 
as to cause serious deformity 
(Plate VI). Usually there is a 
great diminution in the trans- 
verse and an increase in the 
antero-posterior diameter of the 
chest. Fig. 37 shows the out- 
line of the chest of a rachitic 
child of two years, compared 
with that of a healthy child of 
the same age. Another frequent 
deformity is the " rachitic gir- 
dle," which consists in a trans- 
verse depression about two 
inches broad, extending from 
one side of the chest to the 
other, just above its lower bor- 
der. A less frequent one is a deep circular depression over the ensi- 
form cartilage. This is sometimes nearly an inch and a half in depth. 
Marked thoracic deformity was seen in twenty per cent of my cases, 
but in only a small proportion was the chest normal. 

The factors in the production of a thoracic deformity are atmospheric 
pressure and soft chest walls, these sinking in at the point where they 
have least resistance, viz., at the junction of the costal cartilages and the 
ribs. When there is any obstruction to the entrance of air, as in bron- 
chitis, hypertrophied tonsils, or adenoid growths of the pharynx, the 
thoracic deformities are exaggerated. Irregular chest deformities depend 
upon the coexistence of pathological conditions in the lungs. Pigeon- 
breast is occasionally seen, but it is doubtful if this depends upon rickets 
alone. 

Spine : In very many of the milder cases this is normal. The most 
characteristic deformity consists in a posterior curve (kyphosis), which 
is a general one, usually extending from the mid-dorsal to the sacral re- 
gion. This existed in forty-six per cent of my cases. In the early part 
of the disease it disappears entirely on suspending the child, or making 
extension upon the extremities; but in cases of long standing it may not 




Fig. 35/ — Rachitic head; Italian child two years old; 
square, prominent forehead and flat vertex. 



226 NUTRITION. 

disappear entirely by these tests. Very much less frequently there is seen 
a rotary curvature. This, in my experience, has been more frequently to 
the left side than to the right — the opposite of the common form of lat- 




Fig. 36. — Rachitic skull from child one year old, showing frontal and parietal bosses and wide 

fontanel. 

eral curvature seen in young girls. Marked lateral curvature in children 
under three years is usually rachitic. 

The clavicle is affected only in severe cases. The usual deformity 
consists in an exaggeration of the anterior curve at the inner third of the 






Fig. 37. — A, horizontal section of a rachitic chest, child two years old, showing lateral furrows ; 
B, section of chest of healthy child of the same age. 

bone, which is somewhat shortened and its extremities enlarged. It is 
not infrequently the seat of green-stick fracture. 



RICKETS. 



227 



Deformities of the pelvis belong to obstetrics rather than to paediatrics. 
The most common rachitic change is a diminution of the antero-posterior 
diameter and a narrowing of the subpubic arch. Irregular deformities, 
sometimes described as " crumpling of the pelvis," are not infrequent. 

Extremities : Deformities of the upper extremities are usually sym- 
metrical. The humerus is affected only in severe cases. It has a forward 
and outward curve, although rarely a very marked one. Both the epi- 
physes are enlarged, although the upper one can not often be made out 
unless the child is very thin. The radius and ulna are frequently affected. 
They present a convexity upon their extensor surface (Plate V), which in 
some cases is very marked, particularly in children who have been creep- 
ing about. Green-stick fractures here are quite frequent. Eachitic 
changes at the epiphyses are more common than in the shaft, enlarge- 
ment of the epiphyses at the wrist being one of the most constant bony 
deformities of rickets (Plate V). It was present in ninety-five per cent 
of my cases. Less frequently similar swellings are seen at the elbow. 
Enlargement of the ends of the meta- 
carpal bones or the phalanges I have 
seen in but two or three extreme cases. 

The lower extremities are rather 
more frequently affected than the upper, 
but in a similar way. The femur is in- 
volved only in severe cases ; it common- 
ly presents a general forward and out- 
ward curve, which is mainly due to the 
weight of the limbs as the child sits. 
Occasionally there is also an outward 
rotation of the femur, where children 
have been allowed to sit much in a 
cross-legged posture. When such chil- 
dren begin to walk, the toes are turned 
very far outward. The principal de- 
formities of the lower extremity are 
bow-leg (Fig. 38) and knock-knee (Fig. 
39). Knock-knee is more common in 
females, and is believed to be due to 
an overgrowth of the inner condyle of 
the femur. Enlargement of both con- 
dyles can be demonstrated in most of 
the marked cases of rickets. The cases 

of slight bow-leg may be due simply to swelling of the epiphyses, the 
shaft of the bone being quite normal. This point I have verified by 
post-mortem observations. Such are probably most of the deformities 
which disappear spontaneously. The most severe cases of bow-leg are 




Fig. 



Typical bow-legs of severe 
form. 



228 



NUTRITION. 




often associated with some degree of antero-posterior curvature, and the 
latter may be the principal deformity. An exaggerated case of this kind 
is shown in Fig. 40. Enlargement of the epiphyses at the ankle is 

usually present when 
it is seen at the wrists, 
and nearly to the same 
degree. Enlargement 
of the upper epiphyses 
of the tibia and the 
fibula is seen only in 
severe cases. The cause 
of the deformities of 
the leg is not, prima- 
rily at least, walking 
too early, since they 
are common in chil- 
dren who have never 
walked ; slight deform- 
ities, however, may be 
aggravated by early 
walking. A change 
which has not been 
sufficiently emphasized 
is the arrested growth 
Of the long bones ; this 
is one of the most char- 
acteristic features of 
rickets. A rachitic child of three years often measures in height six or 
eight inches less than a healthy child of the same age, the difference being 
almost entirely in the lower extremities. 

All the ligaments, but particularly those about the large joints, are lax 
and frequently elongated. This may lead to the deformity known as weak 
ankles, or to an overextension at the knee {genu recurvatum) ; also to 
unnatural mobility at the hips, shoulders, elbows, and wrists. The condi- 
tion of the ligaments plays an important part in the production of spinal 
deformities. 

Muscles. — The muscular symptoms of rickets are almost as constant 
and as characteristic as those of the bones. The muscles are small, very 
flabby, and poorly developed ; hence rachitic children are unable to sit 
erect, or to stand or walk at the proper age. Of one hundred and fifty- 
one cases in which the date of walking alone was investigated, only twenty- 
seven, or eighteen per cent, walked before the fifteenth month ; forty- 
seven per cent were not walking at the eighteenth month ; twenty per 
cent not at two years ; and ten per cent not at two and a half years. Late 






..' !•_;• ' ■";, ' ', ■ ' . ■ \ ■■ 



Fig. 39. — Knock-knee. 



v Jf 



RICKETS. 



229 



walking is one of the most common symptoms for which advice is sought 
by parents with rachitic children. The muscular power in the extremities 
is sometimes so feeble as to suggest paralysis. I have seen a number of 
cases in which the symptoms so resembled paralysis, that even expert diag- 
nosticians were unable to differentiate rickets from poliomyelitis except 
by the electrical reactions, those in rickets being usually normal or exag- 
gerated. In other cases the symptoms may suggest cerebral palsy of the 
flaccid type. The muscular symptoms may be marked when the bony 
changes are slight, and conversely. As no lesions of the muscles have 
been demonstrated, the symptoms are probably due to imperfect nutri- 
tion. Two other symptoms depend chiefly upon the condition of the mus- 
cles, viz., pot-belly and constipation. 

Pot-belly is quite an early symptom, and in most cases a very marked 
one (Plate V). It was noted in sixty per cent of my cases. The en- 
largement of the abdomen is uniform. It is everywhere tympanitic, and 
it may be as tense as 
a drumhead. It is due 
to a loss of tone in 
the abdominal mus- 
cles, and in the mus- 
cular walls of the stom- 
ach and intestine. It 
is aggravated by chron- 
ic indigestion and con- 
sequent intestinal pu- 
trefaction. The en- 
largement is thus 
mainly from tympa- 
nites. There may be 
a marked degree of 
dilatation both of the 
stomach and the colon. 
To a very small degree 
only, does the large 
abdomen depend upon 
swelling of the liver or 
spleen. 

The constipation of 
rickets, as already 

hinted, depends upon the loss of tone in the muscular walls of the intes- 
tines. It may alternate with diarrhoea. It rarely happens that a rachitic 
child has habitually normal evacuations from the bowels. Hard, dry, 
constipated stools frequently set up a condition of chronic catarrh of the 
colon in which laro-e masses of mucus are discharged. 



V 




> 




40. — Extreme rachitic deformities of the legs. 



230 NUTRITION. 

During the most active part of the disease — viz., from the third to 
the ninth month — tenderness may sometimes be elicited by pressure upon 
the epiphyses. This, however, is not a constant symptom, and a very 
unreliable one for diagnosis. In my own experience it has been marked 
in but a very small proportion of the cases. Acute tenderness should 
always suggest scurvy rather than rickets. 

Fever. — According to some observers there is a febrile movement 
which belongs to the active stage of rickets, but I have never been able to 
satisfy myself of the truth of this observation. • 

Dentition. — As a rule, dentition is late and apt to be difficult — i. e., it 
is associated with attacks of indigestion or other disturbances which may 
be serious. Individual cases, however, present great variations in regard 
to this symptom. A study of the progress of dentition in one hundred 
and fifty rachitic children gave the following results : in fifty per cent the 
first teeth were cut on or before the eighth month, and "in thirteen per 
cent on or before the fifth month ; however, twenty per cent of the cases 
had no teeth at twelve months, and in eight per cent none had appeared 
at fifteen months. Even though the first teeth come at the usual time, 
the progress of dentition is often arrested by the development of rickets, 
and no advance made for five or six months. The difference in the 
cases appears to depend very much upon the age of the child when rick- 
ets begins. Those who give no evidence of it until nine or ten months 
old often have a nearly normal dentition, while the cases developing 
early show a marked retardation of this process. The order in which 
the teeth appear may be very irregular, but there is no rule in this 
respect. The character of the teeth in rickets, in the great majority of 
cases, is good. This was true in eighty-four per cent of one hundred and 
twenty-six cases examined with reference to this point. This is in strik- 
ing contrast to hereditary syphilis, where the tendency to early decay is 
so constantly seen. 

General appearance. — Eachitic patients are almost always ansemic. 
The blood is low in haemoglobin, often down to thirty or forty per cent. 
In some few cases there is in addition quite marked leucocytosis. The 
number of red globules is not often nor uniformly affected. The majority 
of rachitic patients are fat and flabby. The tissues are soft and have but 
little resistance. Rarely, they may be thin, like patients suffering from 
marasmus. 

Rachitic patients are very prone to suffer from hypertrophied tonsils, 
adenoid growths of the pharynx, and enlargements of the lymph nodes of 
the neck. In all forms of acute illness the feeble resistance of these 
patients is very evident. This is especially true of acute disease of the 
lungs. 

The mucous membranes are very vulnerable in all rachitic patients. 
From the slightest indiscretion in diet an attack of acute indigestion or 



RICKETS. 231 

diarrhoea is brought on, and from a very insignificant exposure, catarrhal 
inflammation of the upper or lower air passages is excited. In rachitic 
patients all such attacks are prone to run a protracted course. Inflamma- 
tion of the trachea and larger bronchi is liable to extend to the smaller 
bronchi and the lungs. 

The downward displacement of the liver and spleen from contraction 
of the chest should not be mistaken for enlargement of these organs. 
Moderate enlargement of the spleen is very common during the stage of 
most active symptoms — i. e., sixth to twelfth month. Great enlarge- 
ment of either liver or spleen is rare, and in such cases it is doubtful 
whether it depends upon the rachitic process. It is rather to be connected 
with the condition of the blood which is developed during the disease. 

Urine. — There are no recent studies of the urine of rachitic patients 
which are reliable. 

Nervous symptoms are among the most frequent manifestations of 
rickets. Restlessness at night has already been mentioned as a promi- 
nent early symptom. Pain and tenderness are rare. A disposition to 
muscular spasm is seen in many cases. There may be laryngismus strid- 
ulus, tetany, or general convulsions. The first two are rare except in 
rachitic patients. All of these probably depend upon defective nutrition 
of the nervous centres. While in all infants, owing to the irritability of 
the nervous centres, convulsions are easily excited from relatively slight 
causes, in those who are rachitic this susceptibility is greatly intensified. 
In them, slight causes are sufficient to bring on either local or general 
convulsions. As a predisposing cause of convulsions in infancy, rickets 
takes the first place. The younger the child and the more active the 
rachitic process, the more frequently do convulsions occur. They belong 
especially to the first year, being most frequent between the third and 
ninth months. The exciting cause of convulsions in these cases is usually 
to be found in the stomach or intestine. 

Course and termination. — Rickets is essentially a chronic disease, and 
its course is measured by months. The active symptoms in most cases 
continue from three to fifteen months, although they occasionally last 
a much longer time. The duration of the symptoms probably depends 
chiefly upon the duration of the exciting cause. That active symptoms 
cease when a child reaches the age of eighteen months or two years, is no 
doubt due chiefly to the fact that at this age the diet is more general, 
and is more likely to furnish what the child needs, and that more fresh 
air is likely to be secured than at an earlier age. 

The earliest symptoms of improvement are a diminution in the nerv- 
ous symptoms, especially in the restlessness at night ; increased muscular 
power, as shown by disposition to stand or walk ; diminution in the 
head-sweats; disappearance of the cranio-tabes ; and improvement in the 
anaemia. The changes in the deformities are very slow, and from month 



232 NUTRITION. 

to month almost imperceptible. When improvement once begins, how- 
ever, it usually goes steadily forward, relapses being exceedingly rare. 

Congenital rickets. — Infants may present at birth the characteristic 
deformities of rickets, and there may be found even the minute bone 
changes of the disease. Such cases are reported to be common in Vienna 
and other large cities of Europe, where mothers during pregnancy have 
lived under unfavourable surroundings. In America, however, congeni- 
tal rickets is a very rare disease. Single cases have been reported by 
Jacobi, J. Lewis Smith, and lately by Townsend. Oases of cretinism have 
sometimes been included under this term. 

Late rickets. — Eare instances have been reported of bony deformities 
in all respects like those of rickets, developing in children from six to 
twelve years old. A number of such have been observed in England. I 
have not seen this disease, nor has a case been seen during the past 
twenty years at the Hospital for Euptured and Crippled, New York, where 
more deformities come under observation than anywhere else in this 
country. 

Acute rickets. — Although from time to time cases have been reported 
under this heading, from a study of the histories it is clear that the great 
majority, if not all of them, were cases of infantile scurvy. It is doubtful 
whether, strictly speaking, there is such a thing as acute rickets. 

Diagnosis. — The diagnosis of rickets is not usually difficult, and after 
carefully examining a case one can not often be in doubt. It is the mild 
cases and the early stages of the disease that are most liable to be over- 
looked. The most important early symptoms for diagnosis are sweating 
•of the head, cranio-tabes, great restlessness at night, delayed dentition, 
and enlarged fontanel. All these, taken separately, may mean something 
else, but collectively they can mean nothing but rickets. In. the later 
stages some of the characteristic deformities are usually present ; the most 
constant are beading of the ribs, enlargement of the epiphyses of the wrists 
and ankles, and bow-legs. 

Special symptoms, when unusually prominent, may give rise to diffi- 
culty in diagnosis. The enlargement of the head may be mistaken for 
hydrocephalus. The delayed dentition and large fontanel of the cretin 
may be passed over as rachitic. Muscular weakness may be so great, 
especially when affecting the legs, as to make it easy to confuse a rachitic 
pseudo-paralysis for actual paralysis due to a cerebral or spinal lesion. 
When walking is much delayed, rickets may be passed over as simple 
backwardness. In nearly all of the last-mentioned group of cases the 
diagnosis may be cleared up by a careful search for the bony changes, 
and by the fact that in rickets there is only a general weakness of all 
the muscles, and not actual paralysis of any limb or group of muscles. 
The greatest difficulty is usually found where the muscular symptoms are 
marked and the bony changes slight, as is not infrequently the case. Here 






RICKETS. 233 

the question is, whether rickets is sufficient to explain all the symptoms, 
or whether in addition some other condition is present. The electrical 
reactions will decide the question of poliomyelitis, while the presence of 
cerebral symptoms and of muscular rigidity in the legs will, in most cases 
at least, mark a cerebral birth-palsy. The bony enlargements of syphilis 
are not likely to be confounded with rickets, if it is remembered that the 
early lesions of syphilis are more like boggy infiltrations over the bones 
than actual swelling of the bone itself, and that when the bone is affected 
it is not at the extremity, but at the junction of the epiphysis and the 
shaft ; the bone changes of late syphilis affect the shaft rather than 
the extremities of the long bones ; where the bone is enlarged near 
the joint it is usually upon one side only. In syphilis there may be 
necrosis, while in rickets breaking down of bone is never seen. From 
scurvy, rickets is differentiated by the absence of marked hyperesthe- 
sia, ecchymoses, and other haemorrhages, the changes in the gums, and 
most of all by the fact that anti-scorbutic diet produces no immediate 
change in the symptoms. The diagnosis of rachitic curvature of the 
spine from vertebral caries will be considered in connection with the 
latter disease. 

Prognosis. — Rickets per se is never a fatal disease. It is, however, a 
large factor in the mortality of the first two years, as the cachexia which 
it produces predisposes strongly to every form of acute disease. It is an 
important etiological factor in certain serious nervous conditions, espe- 
cially convulsions. According to Gowers, ten per cent of the cases of 
epilepsy are in children who have suffered from rickets. Eickets adds 
very greatly to the danger of all acute diseases of infancy, particularly 
those of the respiratory tract. This depends partly upon the feeble mus- 
cular power and partly upon the thoracic deformities. The encroach- 
ment upon the capacity of the lungs by a marked thoracic deformity, may 
in itself be enough to keep a child in a delicate condition and retard its 
growth. At the same time such a condition is a constant invitation to 
acute attacks of bronchitis or pneumonia. The effect of rickets upon 
the future health of the child, depends chiefly upon the presence and ex- 
tent of the thoracic deformity. When this is absent, as a rule no serious 
after-effects are visible, and although children may remain somewhat 
dwarfed on account of their short legs, in other respects they may be as 
well as if they had never been the subjects of rickets. 

Prophylaxis. — As rickets is primarily due to improper food or feed- 
ing, and secondarily to bad surroundings, it may be prevented by the 
observance of proper rules of feeding as laid down elsewhere, and by re- 
moving children from their faulty surroundings. Especial care should be 
given to the later children of a family where the earlier ones have shown 
even the mildest symptoms of rickets, as the predisposition is sure to in- 
crease with each child. 
20 



234 NUTRITION. 

Treatment. — In considering the treatment of rickets, the natural 
course of the disease is to be kept in mind, viz., that active symptoms 
usually continue only until the eleventh or twelfth, rarely longer than the 
eighteenth month, and that after this time the patient suffers more 
from the results of the disease than from the disease itself. The most 
important period for treatment, therefore, and the one in which it is 
most effective, is from the sixth to the fifteenth month. The earlier 
the treatment is begun the better will be its results. Constitutional treat- 
ment after the fifteenth or eighteenth month, has very little effect upon 
the disease, for by this time most of the harm has been done. The course 
of the disease when untreated is toward spontaneous recovery, from the 
changes in diet and life which are usually made when children have 
reached the latter half of the second year. Most of the cases seen in 
private practice are of a mild type and recover without special treat- 
ment, often no diagnosis being made until later in life, when the bony 
deformities or stunted growth indicate the previous existence of rickets. 
The first step in treatment is to remove the cause, and is therefore to be 
directed to the diet and hygiene of the patient. The results will depend 
upon how completely these causes can be removed. 

Diet. — Carbohydrates, including sugars, proprietary infant-foods, and 
all farinaceous substances, should be reduced to the minimum, and in 
some cases prohibited. So far as possible the diet should consist of 
nitrogenous food and fats, especially milk, cream, eggs, red meat and 
fresh fruit. These articles are to be given according to the rules laid 
down in the chapters on Infant Feeding. In addition, cod-liver oil — 
which in these cases may be considered quite as much a food as a medi- 
cine — should be administered as soon as the stomach will tolerate it. 

Hygiene. — This is the most difficult part of the treatment. In large 
cities it is almost impossible to secure for rachitic patients the surround- 
ings they require. Whenever possible, such children should be sent to the 
country ; but where this is out of the question, much may be accom- 
plished by frequent excursions upon the water or into the country, by 
keeping children as much as possible in the parks and open squares of the 
city, and securing plenty of fresh air in sleeping rooms. Mothers are 
often very much afraid of fresh air, on account of the tendency of these 
children to take cold. If cold sponge-baths are given every morning, 
much can be done to lessen this susceptibility. Sunshine, though diffi- 
cult to obtain in large cities, is a most efficient therapeutic agent. The 
establishment of suburban hospitals and homes for these cases would do 
more than anything else to lessen the mortality from rickets. 

In a disease which tends so uniformly to recovery when causal condi- 
tions are removed, it is difficult to estimate the real value of medicinal 
treatment. No one thinks of relying upon drugs alone in the treatment 
of rickets, and where they are used in conjunction with other means it 



RICKETS. 235 

is illogical to attribute all the improvement to the drugs employed. 
Those most used are cod-liver oil, phosphorus, and various preparations 
of lime. Regarding the value of cod-liver oil, there can be no question. 
While it can not be ranked as a specific in rickets, it should be given 
in every case unless contraindicated by the condition of the stomach, 
except possibly during very hot summer weather. Phosphorus has been 
popularized in the treatment of rickets by Kassowitz, who regards it as a 
specific for the disease. I have been unable to satisfy myself, after five 
years' experience with its use, that in the great majority of the cases it 
had any decided influence upon the course of the disease. The best 
results from phosphorus are obtained in the early cases, where there are 
cranio- tabes and marked nervous symptoms. But even here I have not 
seen the striking benefit reported by others. In the later stages of rick- 
ets, it has been difficult to see any special result from its use. Phos- 
phorus may be administered either in the form of the officinal oil of 
phosphorus diluted with olive oil, or as Thompson's solution. The dose 
is gr. g-J-g- three times a day, given after meals ; it should be continued 
for several months. In such doses I have never seen it cause unpleasant 
symptoms. 

The absence of lime in rachitic bones has led to the use of various 
preparations of lime as remedies. Those most employed are the phos- 
phate, the lactophosphate, and the hypophosphite. While these may be 
beneficial as tonics, they are not in any sense to be classed as specifics. It 
is probable that when lime is given in excess of the amount furnished by 
ordinary breast-milk or cow's milk, this excess passes through the bowels 
unabsorbed. Arsenic and iron are valuable in the treatment of rickets, 
the special indication for their use being the presence of marked anaemia. 
Profuse sweating may be relieved by small doses of atropine — i. e., gr. 
5^-q-, three or four times a day, to a child of six months. 

Treatment of the rachitic deformities. — The deformities of the chest 
are less amenable to treatment than most of the others. After the third 
year something can be done by gymnastics to develop the chest muscles 
and to increase the pulmonary expansion. The employment of the pneu- 
matic cabinet, in which it is sought to overcome these deformities by the 
use of rarefied air, has never been given the trial which it deserves. From 
the very meagre reports published, this appears to be of considerable value. 

The deformity of the spine (kyphosis) may usually be overcome by 
postural treatment. The patient should lie upon a hard bed ; no pillow 
should be allowed under the head, but in severe cases one should be 
placed beneath the back, so that the head and buttocks are slightly lower 
than the lumbar spine. While sitting, the shoulders should be kept back 
and the trunk supported. For a few minutes each day the child should 
be placed upon the face, and the deformity overcome by raising the but- 
tocks while pressure is made upon the spine. In severe cases, an apparatus 



236 



NUTRITION. 



for giving spinal support, either by a steel brace or a plaster-of- Paris 
jacket, may be worn a few hours each day when the child is sitting up. 
Other means should be employed, especially friction and massage, to 
develop the spinal muscles. 

In very many cases slight deformities of the extremities are outgrown 
when the general treatment can be properly carried out. Where these 
exist, the physician should take the curve of the limbs by seating the 




Fig. 41. — Tracing, showing the curve in a case of bow-legs. 



child upon a fiat surface and tracing their outline with a pencil held per- 
pendicularly (see Fig. 41). A fresh tracing should be taken once a month. 
If the deformity is not very great and no increase takes place, it is safe 
to continue with general treatment only. If the deformity is marked or 
if it increases in spite of the constitutional treatment, braces should be 
applied. Something may be done toward straightening the bones by 
intelligent manipulation. Walking should be discouraged until the bones 
are quite firm. Friction of the extremities, and even the use of electricity, 
will do very much to increase muscular development. The habit of sitting 



KICKETS. 237 

cross-legged — a very common one of rachitic children — should be pre- 
vented, and in fact any other habitual posture, on account of the danger 
of increasing certain deformities. But little is to be expected from the 
use of apparatus for the correction of rachitic deformities after the child 
is two and a half years old ; since at this time, and often even at two years, 
the bones are so firm that no amount of pressure from a steel brace will 
have any effect. 

Without going fully into the question of the surgical treatment of 
rachitic deformities, for which the reader is referred to text-books on 
general and orthopedic surgery, I will only state that osteotomy seems to 
me to offer decided advantages over the other means of treating severe 
deformities. A vast amount of time and patience is wasted in the vain 
attempt to overcome very marked deformities by apparatus. The best 
results in osteotomy are obtained when the operation is delayed until the 
fourth or fifth year, by which time the bones are sufficiently firm and 
solid. Operations in the second year are generally unsatisfactory, and 
those in the third year often so, because of the bending of the bones 
which takes place subsequently. The deformities which require opera- 
tion are bow-leg and knock-knee, less frequently the curvatures of the 
femur or of the bones of the forearm. 



SECTION III. 

DISEASES OF THE DIGESTIVE SYSTEM. 

CHAPTEE I. 

DISEASES OF THE LIPS, TONGUE, AND MOUTH. 

MALFORMATIONS. 

Harelip. — This is one of the most frequent congenital deformities. 
It is caused by an incomplete fusion of the central process with one or 
both of the lateral processes from which the upper half of the face is de- 
veloped. This deformity may be single or double ; the fissure is never in 
the median line, but usually just beneath the centre of the nostril. There 
may be simply a slight indentation in the lip, or the fissure may extend to 
the nostril. Both single and double harelip— more frequently the latter — 
may be complicated by fissure of the palate. Double harelip is usually 
accompanied by a fissure between the intermaxillary and the superior 
maxillary bone of each side. 

Cleft Palate. — This is second in frequency to harelip. It may involve 
the soft palate only, or the fissure may extend into the hard palate, pro- 
ducing a wide gap in the roof of the mouth. The most frequent form 
is that in which only the soft palate is affected. 

For the surgical treatment of both these deformities the reader is re- 
ferred to text-books upon surgery. As to the time of operation,- in cases 
of harelip it is wisest to defer interference until the child is well started in 
its growth — that is, the second or third month — and in cleft palate until the 
third or fourth year. The medical treatment of these cases consists in the 
care of the mouth and in the nutrition of the patient. The mouth in all 
cases must be kept scrupulously clean, but the greatest care is necessary 
not to injure the epithelium. A camel's-hair brush and plain lukewarm 
water, or a weak alkaline solution, are to be recommended. Both these 
deformities are exceedingly likely to be complicated by thrush. This is a 
serious menace to the success of any operation, and even to the life of the 
patient. The nutrition is always a matter of much difficulty, and a very 
large number of these cases die of inanition or marasmus. In cases of 
harelip, if the fissure is so great as to interfere with nursing, the child 
may be fed with a spoon or a medicine dropper until the operation 

238 



DISEASES OF THE TONGUE. 239 

can be done. In cleft palate there may be attached to the rubber nipple 
of the nursing bottle a flap of thin sheet rubber in such a way that it 
closes the fissure in the mouth when once the nipple is in place. This 
flap should be shaped like a leaf, one extremity being sewed to the neck 
of the rubber nipple and the other end left free. In many cases, both 
before and immediately after operation, gavage (page 62) may be resorted 
to with the greatest benefit and with very little inconvenience. 

Congenital Hypertrophy of the Tongue. — This is usually due to disease 
of the lymphatics, and is to be regarded as a lymphangioma. In a few 
cases hypertrophy of the muscular fibres has been present. The tongue 
may reach an enormous size, so that it is impossible for it to be contained 
within the cavity of the mouth, and it may thus interfere with nursing, 
deglutition, and even with respiration. The treatment is surgical. Cases 
like the above are to be distinguished from those of enlargement of the 
tongue seen in sporadic cretinism. In this disease the tongue is consider- 
ably enlarged and may protrude slightly from the mouth, but it is rarely, 
if ever, large enough to cause other symptoms. It diminishes notably 
under treatment with the thyroid extract. 

Bifid Tongue. — These cases are extremely rare. Brothers has reported 
to the New York Pathological Society a case of cleft tongue in a child of 
one month. There was, in addition, a fissure of the soft palate. 

Tongue-Tie. — This deformity is due to such a shortening of the frenum 
that it is impossible to protrude the tongue to a normal extent. It 
differs considerably in degree in different cases. In some, the tongue 
can not be advanced beyond the gums. Tongue-tie may interfere with 
articulation, and even with sucking. The treatment consists in liberating 
the tongue by dividing the frenum with scissors and completing the oper- 
ation with the finger nail. This should be done in every case unless the 
child is a bleeder. In many cases the mother may think the tongue tied 
when the frenum is of normal length. 

Bifid Uvula. — This is not very uncommon. It usually occurs in con- 
nection with cleft palate, but is occasionally seen when there is no other 
deformity present. It may be complete or partial, and it does not of itself 
require treatment. 

DISEASES OF THE LIPS. 

Herpes. — Herpes labialis is an exceedingly common affection in chil- 
dren, occurring in acute febrile diseases, particularly pneumonia, and 
sometimes alone. It is the familiar " fever sore " or " cold sore " of do- 
mestic medicine. The appearance is similar to herpes in other parts of 
the body. There is first a group of vesicles, then rupture and the forma- 
tion of crusts. It is often quite difficult to cure on account of the dispo- 
sition of children to pick the lip with the fingers. Although it heals with- 
out treatment, recovery is facilitated by the use of some antiseptic lotion, 



240 DISEASES OF THE DIGESTIVE SYSTEM. 

such as dilute boric acid, followed by a dusting powder of zinc oxide and 
boric acid. This treatment is generally more successful than the use of 
ointments. Young children should wear mittens at night, to prevent 
picking at the crusts. 

Eczema of the Lip. — This is an exceedingly common condition, and 
a very troublesome one. The vermilion border is dry and rough, and 
prone to deep cracks or fissures. These are usually seen at the angles of 
the mouth or in the median line. When severe they are exceedingly 
painful, bleed freely, and are the cause of very great discomfort, especially 
in the cold season. The lips should be covered at night by simple oint- 
ment, and this should be used as much as possible during the day. 
Where deep fissures form, they should be touched with burnt alum, or 
with the solid stick of nitrate of silver. Syphilitic fissures are considered 
with the symptoms of that disease. 

Perleche (French, perlecher = to lick). — This name was first given by 
Lemaistre, in 1886, to a form of ulceration occurring usually at the angle 
of the mouth. It begins in most cases as a small fissure, which, by con- 
stant licking and irritation, to which there is usually added infection, may 
produce an intractable ulcer of considerable size. It often resembles the 
mucous patch of hereditary syphilis. The ulcer is of a grayish colour, is 
quite painful, and is associated with considerable swelling of the lip. It 
lasts from two to four weeks. The treatment is the same as in simple 
fissure — viz., the use of burnt alum or nitrate of silver, and covering the 
part with bismuth or oxide of zinc. 

DISEASES OF THE TONGUE. 

Epithelial Desquamation. — This is a disease of .the lingual epithelium,, 
which is characterized by the appearance upon the dorsum or margin of 
the tongue, of circular, elliptical, or crescentic red patches, with gray 
margins which are slightly elevated. It is sometimes improperly called 
psoriasis of the tongue. It is quite a common condition. 

The beginning of the disease is not often seen. It is stated first to 
appear as a white or gray patch, like thickening of the epithelium. These 
patches enlarge quite rapidly, and are followed by detachment of the 
epithelium . and the formation of bright red areas, which are the parts 
denuded of epithelium. As usually seen, there exists upon the tongue 
from two to half a dozen of these red patches surrounded by a gray bor- 
der, which is about one twelfth of an inch wide, and slightly elevated. 
The outline of the patch is nearly always crescentic (see Fig. 42). From 
day to day the configuration of the patches changes ; the gray lines advance 
across the tongue from side to side, or from base to tip, disappearing as 
they reach the border or the extremity. They are followed by the red 
patches, and as the old ones fade away new ones form and run the same 
course. The white border seems to be made up entirely of epithelium* 



GLOSSITIS. 



24:1 



The red patches are of a bright colour nearest the border, gradually 
shading off into the normal colour of the tongue. Only the epithelium is 
involved, the deeper structures being unaffected. The duration of the 
disease is indefinite ; it usually lasts for months, and often for years. 
Guinon reports several cases in which a cure took place during an inter- 
current attack of measles or scarlet fever. 

The cause is unknown. The condition occurs rather more frequently 
in females than in males, and Gubler has reported an instance of several 
members of the same family being affected. 
Most of the cases are seen in infancy and 
early childhood. The condition has been 
thought to depend upon nearly every disease 
of this period. Parrot believed that it was 
always syphilitic, but this view has been 
effectually disproved by subsequent observa- 
tion. The disease is not accompanied by 
pain, salivation, or by other symptoms of 
stomatitis, and it is of little practical impor- 
tance. Its symptoms are so characteristic 
that it can hardly be mistaken for any other 
condition. Treatment is unnecessary. 

Two other forms of epithelial desquama- 
tion have been observed, both much more 
rare than that described. In one of these 
the red denuded portion occupies the margin of the tongue, while the 
centre is gray or white ; the irregular wavy outline which separates the two 
suggests strongly an outline map, and the condition is sometimes called 
the " geographical tongue." In another variety nearly the whole organ 
may be uniformly red, from loss of the epithelium, there being no borders 
or patches. Both these varieties are of much shorter duration than the 
more common form, usually lasting only a few weeks.* 

Glossitis. — Inflammation of the tongue is not very common in chil- 
dren. It is usually of traumatic origin. The injury may be due to biting 
the tongue in a fall or in an epileptic seizure. Glossitis is sometimes 
excited by the irritation of a sharp tooth, causing a wound which may be 
the avenue of infection ; or it may result from taking into the mouth 
irritant or caustic poisons. In a small number of cases no cause can be 
found. The symptoms are marked swelling of the tongue, so that it may 
protrude from the mouth ; and it may even be so great as to cause se- 
vere dyspnoea. There are also profuse salivation, difficulty in swallowing 




Fig. 42. — Epithelial desquamation 
of the tongue. (Guinon.) 



* For a fuller description and literature of the subject, see Guinon, Revue Men- 
suelle des Maladies de l'Enfance, 1887, p. 585 ; and Gautier, Revue Medicale de la 
Suisse, Romande, October and November, 1881. 



242 DISEASES OP THE DIGESTIVE SYSTEM. 

and in articulation, and often considerable local pain. There may be a 
rise of temperature to 102° or 103° F. The treatment consists in the use 
of fluid food, which in severe cases may be introduced through the nose 
by means of a catheter. Ice may be used externally, or, better still, pieces 
of ice should be kept in the mouth continually. If there is obstruction to 
respiration, and in all severe cases, scarification should be done on the dor- 
sum along the side of the raphe. 

Tongue-swallowing. — This term is used to describe a rare condition 
seen in infants, in which the tongue is turned backward into the pharynx, 
so as to obstruct respiration. It may be drawn quite into the oesophagus. 
Several marked cases have been collected by Hennig.* One of these will 
suffice as an illustration. A well-nourished infant of three months, in the 
course of a severe paroxysm of pertussis, was seized with convulsions, fol- 
lowed by asphyxia, and died in a few minutes. After death the tongue 
was found to be doubled upon itself, its tip being tightly wedged into the 
oesophagus. While most frequently occurring with pertussis, tongue- 
swallowing has been seen in other diseases. I have never met with cases 
of such severity, although in several instances I have seen marked dysp- 
noea produced in young infants by the folding backward of the tongue. 
Tongue-swallowing should not be forgotten as one of the explanations of 
sudden asphyxia in a young infant. The conditions necessary to its pro- 
duction are a somewhat relaxed organ or a long frenurn. In none of the 
fatal cases reported, however, had the frenum been divided. In some 
weak infants, falling back of the tongue, so that its base partly covers the 
epiglottis, produces asphyxia, precisely as it occurs in adult life under 
full anaesthesia. The recognition of the condition is a very easy one, and 
its treatment is to relieve the obstruction by drawing the tongue forward 
by the finger or forceps. 

Ulcer of the Frenum. — The friction against the. sharp edges of the lower 
central incisors frequently causes an ulcer of the frenum in infants. I have 
never seen it in older children. It usually occurs in pertussis, but is seen 
in other cases. In some it appears to be produced by friction of the 
teeth during nursing from the breast or bottle. It is more often seen in 
children who are delicate or cachectic than in those who are healthy and 
well nourished. The ulcer may be confined to the frenum, or it may 
extend quite deeply into the tongue. It is usually about one fourth of 
an inch in diameter, and of a yellowish-gray colour. When not readily 
cured by touching with alum or nitrate of silver, the child may be fed by 
gavage for several days, or the teeth may be covered by a bit of absorbent 
cotton. 

* Jahrbuch fur Kinderheilkunde, xi, 299. 



ALVEOLAR ABSCESS— DIFFICULT DENTITION. 243 

ALVEOLAR ABSCESS. 

This is common in children, especially among the class of hospital and 
dispensary patients, in whom little or no attention is given to the care of 
the teeth. It causes severe pain and acute swelling, which may be limited 
to the gum, or it may involve to a considerable extent the periosteum of 
the jaw, and even cause swelling of the whole side of the face. If there 
is retention of pus, there may be quite severe constitutional symptoms, 
such as a chill and high temperature ; but in most of the cases these are 
wanting. The abscess usually opens spontaneously into the mouth, but it 
may open externally if the molar teeth are the ones affected. It may 
even lead to necrosis of the jaw. If its site is the upper jaw, the pus may 
find its way into the nasal cavity or into the maxillary sinus. 

The treatment is, in the first place, prophylactic. This requires atten- 
tion to the teeth to prevent decay, and the removal of old carious fangs, 
which are a constant menace to the health of the child in more ways than 
one. The free use of the toothbrush and some antiseptic mouth-wash 
will, in the great majority of cases, prevent the occurrence of this disease. 
It is important that the abscess be opened early and free drainage secured. 
If there is a carious tooth it should be drawn. 

DIFFICULT DENTITION. 

The place of dentition as an etiological factor in the diseases of infancy 
is one which has given rise to much discussion. From a very early period 
the view has descended, that a large number of the diseases occurring be- 
tween the ages of six months and two years were due to difficult dentition. 
The list of such diseases is a long one, but year by year it has been short- 
ened as one after another has been shown to depend upon other causes, 
dentition being only a coincidence. 

At the present time many good observers deny that dentition is ever a 
cause of symptoms in children ; some even going so far as to say that the 
growth of the teeth causes no more symptoms than the growth of the 
hair. Without doubt the usual mistake made in practice is in overlooking 
serious disease of the brain, kidneys, lungs, stomach, and intestines, because 
of the firm belief that the child was " only teething." The physician who 
starts out with the idea that dentition may produce all symptoms in in- 
fancy, usually gets no further than this in his etiological investigations. 
Although I strongly believe that the importance of dentition as an etio- 
logical factor in disease has been in the past greatly exaggerated, and 
although I have formerly held the opinion that simple dentition did not 
and could not produce symptoms, within the past few years I have been 
compelled by clinical observations to change my opinion upon this sub- 
ject ; and I am now willing to admit that dentition may produce many 
reflex symptoms, some even of quite an alarming character. 



244 DISEASES OP THE DIGESTIVE SYSTEM. 

Speaking from impressions, not from statistics, I should say that in 
my experience about one half of the healthy children cut their teeth 
without any visible symptoms, local or general ; in the remainder some 
disturbance is usually seen, and though in most cases it is slight and of 
short duration, it may last for several days or even a week. The symptoms 
most commonly seen are disturbed sleep, or wakefulness at night and 
fretfulness by day, so that children often sleep only one half the usual 
time. There is loss of appetite, and much less food than usual is taken. 
There is often, but not always, an increase in the salivary secretion, a 
slight amount of catarrhal stomatitis, and a constant disposition on the 
part of the child to stuff the fingers into the mouth. The bowels are 
often constipated or there may be slight diarrhoea. The thermometer 
may show a slight elevation of temperature to 100° to 101-5° F. The 
weight may remain stationary for a week or two, and there may even be 
a loss of a few ounces. The duration of these symptoms in most cases is 
but a few days, and they require no special treatment. If the food is 
forced beyond the child's inclination, attacks of indigestion with vomit- 
ing and diarrhoea are easily excited. 

Symptoms more severe than the above are rare in healthy children, but 
are not infrequent in those who are delicate or rachitic. In such suscep- 
tible children, even so slight a thing as dentition may be the cause, or at 
least the exciting cause, of quite serious symptoms. Often there is some 
other factor in the case, such as bad feeding or feeble digestion. In deli- 
cate or rachitic children there may be seen the symptoms already men- 
tioned as occurring in healthy infants, but in greater severity ; and in 
addition there may be severe attacks of acute indigestion. Occasion- 
ally there is quite high fever, from 102° to 104° F., lasting usually only 
two or three days, but in rare cases for a week, and accompanied by no 
other symptoms except almost complete anorexia. Convulsions which 
could fairly be attributed to dentition I have never seen, yet I do not 
doubt that they may occur in rachitic children. There are certain cases 
of eczema in which the symptoms undergo a distinct exacerbation with 
the eruption of each group of teeth. As regards almost all the other dis- 
eases which are commonly attributed to dentition, I believe that it is a 
delusion to trace them to this cause. 

The physician should watch a child carefully, and examine it fre- 
quently, to be sure that he is not overlooking some serious local or consti- 
tutional disease before he allows himself to make the diagnosis of difficult 
dentition. Probably in ninety-five per cent of the cases in which the 
above symptoms are present, they are due to some cause other than denti- 
tion. When, however, symptoms such as any of those mentioned disap- 
pear immediately when the teeth come through, and when we see them 
repeated four or live times in the same child with the eruption of each 
group of teeth, and accompanied by red and swollen gums, I think we can 



CATARRHAL STOMATITIS. 245 

not escape the conclusion that dentition has been a factor in their pro- 
duction, though perhaps not the only one. 

In the treatment of this condition drugs occupy but a small place. It 
should be remembered that infants are at this time in a peculiarly suscep- 
tible condition, as regards the digestive tract, and attacks of indigestion, 
and even severe diarrhoea, are readily excited from slight causes, espe- 
cially from overfeeding. Special care should be exercised in this respect. 
The strength of the food should be reduced, as well as the amount 
given. The poor appetite indicates a feeble digestion, which should not 
be overtaxed. . As attacks of bronchitis and acute nasal catarrh are read- 
ily induced, even slight exposure should be guarded against. The nervous 
symptoms, when severe, may be relieved by the use of moderate doses of 
bromide and phenacetine, better than by opiates. All soothing syrups 
should be discountenanced. All the various devices for making denti- 
tion easy are a delusion. In a small number of cases lancing the gums 
is of decided value. I have myself seen marked and undoubted relief 
given by it. This is likely to be the case where the gums are tense, 
swollen, and very red, with the teeth just beneath the mucous membrane. 
That lancing the gums is often required I do not believe; that it is 
done by many physicians too frequently is no doubt true ; but it should 
still have a place in our therapeutic measures. Care should always be 
taken that infection is not carried by the lancet. 

CATARRHAL STOMATITIS. 

This is characterized by redness and swelling of the mucous mem- 
brane, and by increased secretion of the salivary and the muciparous 
glands of the mouth. It usually involves a large part of the mucous 
membrane. 

Etiology. — Catarrhal stomatitis may result from traumatism. This 
injury may be mechanical, or due to heat or any irritant accidentally 
taken into the mouth. It frequently occurs at the time of the eruption 
of a tooth. It complicates measles, scarlet fever, diphtheria, influenza, 
and many other infectious diseases. In these cases,, and in many others, 
the disease is probably due to direct infection. 

Lesions. — The lesions are essentially the same as in catarrhal inflam- 
mations of other mucous membranes. There are congestion with desqua- 
mation of epithelial cells, and sometimes the formation of superficial 
ulcers. The process may be a very superficial one, or it may extend to 
the submucous tissue. 

Symptoms. — The whole mucous membrane is intensely injected, all 
the capillaries are dilated, and small haemorrhages easily excited. The 
mucous membrane is swollen, this being most apparent over the gums or 
about the teeth. There may be some swelling of the lips. The mouth 
seems hot, and the local temperature is certainly increased. There is con- 



246 DISEASES OF THE DIGESTIVE SYSTEM. 

siderable pain, as shown by f retf ulness, but particularly by the disinclination 
to take food : infants, though evidently hungry, either refusing the breast 
or bottle altogether, or dropping it after a few moments. The increase in 
secretion is sometimes marked, so that the saliva pours from the mouth, 
irritating the lips and face and drenching the clothing. In other cases 
the saliva is swallowed. On close inspection there may be seen swelling 
of the muciparous follicles, and even the formation of tiny cysts from the 
accumulation of secretion within them (Forchheimer). The tongue is 
usually coated, the edges reddened, and the papillae prominent. In febrile 
diseases, such as typhoid, etc., we may get an accumulation of dead epi- 
thelium with the formation of cracks and fissures of the tongue, and the 
lips may present a similar condition. The neighbouring lymphatic glands 
are slightly enlarged and tender. The constitutional symptoms accom- 
panying simple stomatitis are not severe, but some disturbance is almost 
always present. There may be derangement of digestion with vomiting, 
and even a mild attack of diarrhoea. In the majority of cases the disease 
runs a short course, recovery taking place in a few days when the primary 
cause is removed. In very delicate children it may be prolonged, and 
from the interference with nutrition may even lead to serious conse- 
quences. 

Treatment. — The mouth and teeth should be kept clean. Food is 
more acceptable if given cold. In very severe cases, where food is refused, 
gavage may be resorted to three or four times daily. In all cases children 
may be given ice to suck. This is refreshing, both on account of the cold 
and from the relief to the thirst. The mouth should be kept clean with 
a solution of boric acid, ten grains to the ounce, or an alkaline solution, 
such as D obeli's, diluted with an equal amount of cold boiled water ; or 
simply water may be used. In the severe forms, where there is much 
swelling and slight catarrhal ulceration, astringents are required. In my 
experience alum is the best ; this may be applied in the form of the pow- 
dered burnt alum mixed with an equal amount of bismuth, or in solution, 
ten grains to the ounce, with a swab or brush. Where ulcers are slow 
in healing and very painful, the powdered burnt alum may be applied 
directly. 

HERPETIC STOMATITIS. 

Synonyms : Aphthous, vesicular, follicular stomatitis. 

In this form of stomatitis we have the appearance first of small 
yellowish-white isolated spots, and subsequently the formation of super- 
ficial ulcers. These ulcers are first discrete, but may coalesce and form 
others of considerable size. It is a self-limited disease, usually running 
its course in from five days to two weeks. 

Etiology. — Very little is as yet positively known regarding the cause 
of herpetic stomatitis. Forchheimer reports bacteriological investigations 



HERPETIC STOMATITIS. 247 

as yielding negative results. I adopt the term herpetic to designate this 
disease, because I believe, with Forchheimer* and others, that it is of 
nervous origin. There is yet lacking sufficient evidence to establish the 
fact that it is contagious. It occurs most frequently about the end of the 
first year, but may be seen at any period of childhood, least frequently 
in very young infants. It is often associated with disturbances of the 
stomach, and an attack may be coincident with the eruption of the teeth. 

Lesions. — The exact nature of the lesion is still a matter of dispute. 
The view generally accepted is, that there is first the formation of a 
vesicle, followed by death of the epithelial cells covering it, and the pro- 
duction of an epithelial ulcer ; the process being thus regarded as analo- 
gous to herpes of the skin. These ulcers may extend superficially, but 
never deeply ; they commonly heal quickly with the formation of new 
epithelial cells, leaving no cicatrices behind them. Herpetic stomatitis is 
always associated with more or less catarrhal inflammation. 

Symptoms. — The symptoms of herpetic stomatitis may precede or 
follow those of a catarrhal inflammation. The characteristic feature is 
the appearance of small, shallow, circular ulcers, usually coming in suc- 
cessive crops. While most frequent at the border of the tongue and the 
inside of the lips, they may be found upon any part of the mucous mem- 
brane of the mouth or the pharynx. There may be only half a dozen 
present, or the mouth may be filled with them. They are first of a yel- 
lowish colour, and on an average about one eighth of an inch in diameter. 
By the coalescence of several smaller ones there may form patches of con- 
siderable size, sometimes nearly covering the lips. The older ulcers are 
apt to have a dirty grayish colour, and in places may look not unlike a 
diphtheritic membrane. The smaller ones are surrounded by a red areola, 
and when healing the margin is of a bright red colour. Their appearance 
is often more like that of an exudation upon the mucous membrane than 
an excavation into it. The other symptoms are much the same as in 
catarrhal stomatitis, but usually of greater severity. The pain is particu- 
larly intense, it being often difficult to induce children to take anything in 
the form of food. The tongue is frequently coated, but there is never the 
foul breath of ulcerative stomatitis. The duration of the disease is from 
one to two weeks, and, if the child is in good condition, complete recovery 
takes place even without any special treatment. In badly nourished chil- 
dren the disease may last for two or three weeks ; relapses may occur, and 
the condition may interfere very seriously with the child's nutrition. 

Treatment. — This is the same as in catarrhal stomatitis, with the addi- 
tion that to each one of the ulcers finely powdered burnt alum should be 
applied with a camePs-hair brush. If this is not effective, the solid stick 
of nitrate of silver may be used. The ulcers will usually yield rapidly to 



* Archives of Paediatrics, ix, 330. 



248 DISEASES OF THE DIGESTIVE SYSTEM. 

this treatment. In my experience, drugs given with the purpose of affect- 
ing the lesion in the mouth have been without benefit. 

ULCERATIVE STOMATITIS. 

This form of stomatitis is only seen when teeth are present. It is 
characterized by an ulcerative process, beginning at the junction of the 
teeth and the gum, and extending along the teeth, involving second- 
arily other parts of the mouth, but never spreading beyond the buccal 
cavity. It occurs from several quite distinct causes, and, while not tend- 
ing to spontaneous recovery, it is in most cases readily curable by the 
internal administration of chlorate of potash, which may be looked upon 
as a specific remedy. 

Etiology. — Ulcerative stomatitis may be due to certain of the metallic 
poisons, particularly mercury, lead, and phosphorus ; but from all these it 
is now rare, and not so often seen in children as in adults. It sometimes 
occurs as a sequel of acute infectious diseases. Most of the cases are seen 
in hospital and dispensary patients, in children whose general health is 
below par and who have suffered from the lack of proper food. In pri- 
vate practice among the better classes, it is a rare disease. A local 
cause of much importance is the common neglect among the poor of 
cleanliness of the mouth and teeth, and the presence of carious teeth. 
This is the form of stomatitis which occurs in scurvy ; and it seems not 
unlikely that an allied disturbance of nutrition, causing a spongy, swollen 
condition of the gums, exists prior to many cases of ulcerative stomatitis. 
Given this state of things, it is easy to see how infectious germs from 
the mouth, finding a ready entrance, may set up an active inflammatory 
process ; the diminished vitality from general condition taking the part 
of a primary cause, and infection that of a secondary one. Bacteriological 
investigations of these cases thus far made, have revealed only the ordi- 
nary pyogenic bacteria. 

Lesions. — The disease may begin at any part of the mouth, but most 
frequently upon the outer surface of the gum along the lower incisor 
teeth. From this point it extends behind the teeth, and from the in- 
cisors to the canines and molars, usually of one side only ; but it may 
involve the whole gum and both jaws. From the gums the process may 
spread to the lips, affecting the fold of mucous membrane between the 
gum and the lip, and also to the inner surface of the cheek, especially 
opposite the molar teeth, where large ulcers often form. In neglected 
cases the disease may extend into the alveolar sockets, the teeth loosening 
and falling out. The periosteum of the alveolar process may be involved, 
and even superficial necrosis of the jaw may occur, as happened in two 
cases that came under my observation. 

Symptoms. — The first things noticed are the very offensive breath and 
the profuse salivation. It is usually for one of these that the patient 



ULCERATIVE STOMATITIS. 249 

is brought for treatment. On inspection of the mouth, there is seen in 
the mild cases, swollen, spongy gums of a deep red or purplish colour, 
which bleed at the slightest touch. There is a line of ulceration, usually 
along the incisor teeth, most marked in the front, which may extend to 
any or to all of the teeth ; sometimes it affects only the gum along the 
molar teeth, the incisors escaping. At the junction of the teeth and gum 
is seen a dirty, yellowish deposit, on the removal of which free bleeding 
takes place. The diseased parts are very painful, and the child cries, 
and resists any attempt at examination. In the more severe cases and in 
those of longer duration the teeth are loosened, sometimes being so loose 
that they can be picked from the gum. There may be necrosis of the 
jaw, and even a loose sequestrum may be found. The ulceration along 
the gums in these cases is deeper, and there may be ulcers in the cheek 
opposite the molar teeth, or inside the lip. The swelling may be so great 
that the teeth are almost covered ; this is seen particularly in the scorbutic 
form. The saliva pours from the mouth, adding greatly to the discomfort 
of the patient. Beneath the jaw are felt the large, swollen lymphatic 
glands, which are painful and tender to the touch, but show no tendency 
to suppurate. The tongue is somewhat swollen, and shows at the edges 
the imprint of the teeth ; it is thickly coated with a dirty yellow fur. 
The general condition of these patients is usually poor, and there may 
be quite a marked cachexia. Other forms of stomatitis, particularly the 
herpetic, may be associated, and it should not be forgotten that the gan- 
grenous form may follow. 

When not recognised or not properly treated, ulcerative stomatitis 
may last for months, and seriously affect the patient's general health. 
When properly treated it tends in all recent cases to rapid recovery, usu- 
ally in a few days. No deformity of the mouth is left, the only untoward 
results being shrinking of the gum, sometimes loss of some of the incisor 
teeth, and more rarely a superficial necrosis of the alveolar process. All 
these are quite uncommon. Ulcerative stomatitis can hardly be con- 
founded with any other form, and not only should a diagnosis of the 
lesion be made, but the condition upon which it depends should, if pos- 
sible, be discovered ; scorbutus, particularly, should not be overlooked. 

Treatment. — The first thing to be done is to remove the cause. When 

dependent upon metallic poisoning the source should be discovered. 

Scorbutic cases should have the usual anti-scorbutic diet. Cleanliness of 

the mouth is of great importance, and this may best be accomplished by 

the use of peroxide of hydrogen diluted with from two to ten parts of 

water. It should be followed by plain water, and repeated several times a 

day. In other cases an astringent solution of alum, five grains to the 

ounce, or a mouth-wash of chlorate of potash, three grains to the ounce, 

may be employed. The only objection to the last mentioned is the pain 

which it usually produces. 
21 



250 DISEASES OF THE DIGESTIVE SYSTEM. 

The specific remedy for ulcerative stomatitis is chlorate of potash. 
The best method of administration is to give two grains or one half tea- 
spoonful of a saturated solution, largely diluted, every hour during the 
day for the first twenty-four hours and subsequently every two hours; 
when improvement occurs the dose may be still further reduced. Marked 
benefit is usually seen in one or two days even in cases that have lasted for 
several weeks. If the case does not yield readily to this treatment there 
is probably disease at the roots of the teeth, and when loose these should 
be removed, and the jaw examined to see if there is necrosis. Occasion- 
ally the ulcers show but little disposition to heal, and require to be 
touched with burnt alum or nitrate of silver. 

The constitutional and dietetic treatment in all these cases should 
be the same as that employed in scurvy — i. e., plenty of fruit, fresh vege- 
tables, and sometimes the internal administration of mineral acids, espe- 
cially aromatic sulphuric acid. Iron is indicated in most of the cases. 

Ulceration of the Hard Palate.— This is usually seen in the first few 
weeks of life, but may occur in any child suffering from marasmus. The 
primary cause may be the injury inflicted in cleansing the mouth. In 
other cases it is due to the friction of the rubber nipple, or something 
else which the child is allowed to suck. In still others it is apparently 
produced by the habit of tongue-sucking frequently observed in these 
young infants. The appearances are quite characteristic : there is formed, 
rather far back upon the hard palate, usually upon both sides, a super- 
ficial ulcer, from a fourth to a half inch in diameter. There are no signs 
of acute inflammation. Thrush may coexist, but it has no relation to the 
production of the disease. Spontaneous recovery usually occurs in from 
one to three weeks, provided the cause can be removed. In children suf- 
fering from marasmus these ulcers are very intractable, and in many 
instances their cure is practically impossible. It is therefore especially 
important to prevent, if possible, their formation by care in cleansing the 
mouth, and in avoiding the other causes referred to. When ulcers have 
appeared they should be treated as cases of herpetic stomatitis. 

THRUSH. 
Synonyms : Sprue ; German, Soor ; French, muguet. 

Thrush is a parasitic form of stomatitis characterized by the appear- 
ance upon the mucous membrane, usually of the tongue or of the cheeks, 
of small white flakes or larger patches. It is common in infants of the 
first two or three months, and in all the protracted exhausting diseases of 
early life. 

Etiology. — The parasite which produces thrush is a form of fungus, 
but the exact class to which it belongs has not yet been definitely settled. 
It is now known that it is not the o'idium albicans, but that it belongs to 



THRUSH. 



251 



the group of the saccharomyces, and the term saccharomyces albicans 
has been given to it. If a little of the exudate from the mouth is placed 
upon a slide and a drop of liquor potassae added, the structure of the 
fungus is readily seen. With the low power of the microscope there 
can be made out fine threads (the mycelium) and small oval bodies (the 
spores). With a high power the threads can be seen to be made up of a 
number of shorter rods, at the ends of which the spore formation takes 
place (Fig. 43). The mycelium is produced from the spores. The spores 
of this fungus are of very 
common occurrence in the at- 
mosphere. The conditions in 
the mouth which favour its 
growth are any pathological 
condition of the epithelium, 
particularly a slight amount 
of catarrhal stomatitis, a scan- 
ty salivary secretion and want 
of cleanliness. The fungus 
may grow in a medium of any 
reaction, but best in one which 
is slightly alkaline or neutral. 
The nature of the process 
which it produces is in all 
probability a sugar fermenta- 
tion, the acid reaction of the 
mouth being the result of the growth rather than its cause. Infection 
may come from another patient by means of a rubber nipple or a cloth 
which has been used for the infected mouth, from the nipple of the nurse, 
or directly from the air. The disease is an exceedingly common one in 
foundling asylums, in all places where many young infants are congre- 
gated, and where cleanliness of mouths, bottles, etc., is neglected. It is 
especially frequent in children suffering from malnutrition, marasmus, or 
other wasting diseases, and in those who have hare-lip, or any deformity 
of the mouth. 

Lesions. — According to Forchheimer, the spores lodge between the epi- 
thelial cells and gradually separate the different layers. This occurs be- 
fore the formation of the white pellicle. Later the disease spreads to 
the surface of the mucous membrane, and also somewhat to the deeper 
layers. It is stated by Wagner that it may invade the blood vessels and 
be carried to distant parts. Although the saccharomyces albicans is com- 
monly found upon flat epithelium, its growth is not confined to it. It 
usually begins at many isolated spots upon the mucous membrane, and 
gradually spreads until coalescence takes place ; a continuous membrane 
may be formed. No pus is produced by the process. 




Fig. 43. — Thrush fungus (highly magnified), a, my- 
celium ; b, spores ; c, epithelial cells from the 
mouth; d, leucocytes ; 6, detritus. (Jaksch.) 



252 DISEASES OF THE DIGESTIVE SYSTEM. 

The usual seat is the tongue, the inside of the cheeks, and the hard 
palate, but not infrequently it involves the lips, the tonsils, the pillars of 
the fauces, and the pharynx. Further extension than this is very rare, 
although cases are on record in which thrush has been found in the 
oesophagus, in the stomach and intestines, and even in the lower respiratory 
tract. I have never seen extension farther than the oesophagus, and this 
but once or twice. I know of but one reported case in this country 
(Northrup's) in which thrush has been seen in the stomach. Cases 
involving the oesophagus and the stomach appear from reports to be much 
more common in Europe. 

Symptoms. — The essential symptoms of thrush are the appearance 
upon the mucous membrane of the mouth — usually beginning upon the 
tongue or the inner surface of the cheek — of small white flakes which 
resemble deposits of coagulated milk, but which differ from them in the 
fact that they can not be wiped off. If forcibly removed, they usually 
leave a number of bleeding points. There may be only a few scattered 
patches, or the mouth and pharynx may be covered. The mouth is gen- 
erally dry, the tongue coated ; food may be refused on account of pain, 
and there may be some difficulty in swallowing. The other symptoms 
depend upon the conditions with which the thrush is associated. 

Diagnosis. — This is rarely difficult. The deposit may be mistaken for 
coagulated milk, but is distinguished by the features just mentioned. 
When existing upon the pharynx and fauces it has been confounded with 
diphtheria, although this mistake can hardly be made if all the features 
of the case are taken into consideration — the age of the patient, the in- 
volvement of the lips and tongue, the dry mouth, the absence of glandular 
enlargement, etc. In any case of doubt the examination of the deposit 
under the microscope at once reveals its true nature. 

Prognosis. — Thrush is not in itself a dangerous disease, except in the 
very rare instances where it may obstruct the oesophagus, and this can 
hardly occur except in a condition of exhaustion which is necessarily 
fatal. In a feeble and delicate infant, thrush may be a serious complica- 
tion by interfering with the taking of sufficient nourishment. With 
proper treatment most of the cases involving only the mouth are readily 
cured. 

Treatment. — Thrush may be prevented in almost every case by due 
attention to cleanliness of the mouth, rubber nipples, bottles, cloths, etc. 
All rubber nipples should be kept in a solution of borax or salicylate of 
soda, and the child's mouth should be cleansed several times a day. On 
no account should a feeding-bottle be passed from one child to another. 

In the treatment of the disease the essential things are cleanliness, and 
the use of some mild antiseptic mouth-wash. The routine treatment which 
I have followed for many years both in hospital and private practice, is to 
cleanse the mouth carefully after every feeding or nursing with a solution 



GONORRHEAL STOMATITIS. 253 

of borax or bicarbonate of soda, ten grains to the ounce, and to apply four 
times a day to the affected mucous membrane a saturated solution of boric 
acid. Both these applications, however, should be carefully made, so as 
not to injure the epithelium. The best method is by the finger wrapped 
in absorbent cotton, or by a swab. Applications to be especially avoided 
are those mixed with honey or any syrup. In several hospital cases the 
disease seemed to be prolonged by the irritation of the rubber nipple of 
the feeding-bottle. In such cases it has been our practice to feed by 
gavage for two or three days, as all cases improved much more rapidly 
when this was done. 

GONORRHEAL STOMATITIS. 

There has been described by Dohrn and Kosinski a form of stomatitis 
in the newly-born, due to a gonorrhceal infection. This is not likely to 
take place unless the epithelium has been removed. The infection in all 
cases occurred from the mother. The lesion consists in the formation of 
yellowish-white patches upon the tongue or hard palate — regions in which 
the epithelium is likely to be injured by rough attempts at cleansing the 
mouth. There may be other evidences of gonorrhoeal infection, such as 
ophthalmia. The diagnosis rests upon the discovery of the gonococcus in 
the exudate. In all the above cases the general health was not affected, 
and recovery followed in the course of a week or ten days. 

The treatment consists in thorough cleanliness and in the application 
of a saturated solution of boric acid, as in thrush. 

SYPHILITIC STOMATITIS. 

The buccal symptoms of hereditary syphilis are important both from a 
diagnostic and therapeutic standpoint. The most frequent lesions are fis- 
sures, ulcers, and mucous patches. Fissures are found upon the lips, most 
frequently at the angle of the mouth, and are usually multiple. They 
may be quite deep and cause frequent haemorrhages. Mucous patches are 
superficial ulcers developing from papules which form upon the mucous or 
muco-cutaneous surface. In cases of acquired syphilis in children the pri- 
mary sore may be seen upon the tongue, the lip, or the tonsil. All these 
symptoms are more fully considered in the chapter on Syphilis. 

DIPHTHERITIC STOMATITIS. 

In severe cases of diphtheria the membrane is found not only upon the 
pharynx and tonsils, but it may appear anywhere upon the buccal mucous 
membrane or the lips. It is questionable whether the diphtheritic process 
ever begins in the mucous membrane of the mouth, or whether it is ever 
confined to this part. In my own experience diphtheritic stomatitis lias 
always been associated with deposits upon the tonsils and pharynx. It 
is seen only in the severest cases, and in those which, from other con- 



254 DISEASES OF THE DIGESTIVE SYSTEM. 

ditions which are present, are almost necessarily fatal. Bearing in mind 
the above points, it can hardly be mistaken for any other variety of stoma- 
titis, although not infrequently the mistake is made of regarding as diph- 
theritic, cases of herpetic stomatitis in which the ulcers have coalesced. 
The treatment, so far as the mouth is concerned, consists in cleanliness by 
frequent gargling or syringing with a saturated solution of boric acid. 
Forcible removal of the membrane is not to be advised. 

GANGRENOUS STOMATITIS. 
Synonyms : Cancrum oris, noma. 

This is a gangrenous process which begins usually upon the gums or 
upon the inside of the cheek, and extends with great rapidity, causing ex- 
tensive destruction of the tissues of the mouth, often perforation of the 
cheek, and usually terminating fatally. It is fortunately a rare disease. 
Although this is usually classed among the diseases of the mouth, the same 
process may occur elsewhere. I have known it to affect primarily the nose 
and the external auditory meatus. Cases affecting the female genitals are 
even more common. 

Etiology. — Gangrenous stomatitis is usually a secondary disease, occur- 
ring most frequently as a complication of measles, but sometimes with 
other exhausting diseases of infancy and childhood. It is not often seen 
except in institutions for children. Whether or not there is a specific form 
of infection has not yet been established. In a recent case occurring in 
the Babies' Hospital streptococci were found in pure culture. Strep- 
tococci chiefly were found in observations by Cornil and Babes, and by 
Kanke. The factors necessary for the production of the disease are a very 
low vitality of the tissues, and infection, which, with our present knowl- 
edge, is most probably by streptococci of a peculiarly virulent type. 

Gangrenous stomatitis often follows some other form, usually the 
ulcerative, although the two can hardly be considered as the same disease, 
differing only in severity. 

Lesions. — The process is one of rapidly spreading gangrene. In most 
of the cases there are thrown out inflammatory products in quite large 
amount, but there is little or no tendency to limitation of the disease. 
This usually advances steadily until death occurs. In a small number of 
cases a line of demarcation finally forms, and the slough separates, leaving 
a large area to be partly filled in by granulation and cicatrization. Other 
infectious processes are likely to accompany the disease, particularly 
broncho-pneumonia. 

Symptoms. — The general symptoms are those of profound prostration 
and sepsis. The constitutional depression may be great at the very be- 
ginning, or the children at first may be in fair condition, but rapidly 
grow worse in the course of two or three days. The temperature is 



GANGRENOUS STOMATITIS. 



255 



usually elevated to 102° or 103° F., and sometimes to 104 c or 105° F. 
There are dulness, apathy, feeble pulse, muscular relaxation, and very 
often diarrhoea. Before death the temperature may be subnormal. 

Of the local symptoms, often the first to attract attention is the odour 
of the breath ; sometimes it is the dusky spot on the cheek or lip. On 
examination of the mouth, there usually is found upon the gum or inside 
of the cheek a dark, greenish-black necrotic mass, surrounded by tissues 
which are swollen and cedematous, so that the cheek or lips may be 
two or three times their normal thickness. Externally the parts are 
tense and brawny from the swelling, this infiltration always extending for 



r 




Fig. 44.— Gangrenous stomatitis, following measles. (From a photograph lent by 
Dr. Henry Moffat.) 



some distance beyond the gangrenous part. As the process extends, the 
teeth loosen and fall out ; there may be necrosis of the alveolar process of 
the jaw and perforation of one or both cheeks or lower lip. Extensive 
sloughing of the face may take place, usually upon one side, sometimes 
upon both, giving the patient a horrible appearance, as shown in Fig. 
44. In this patient the process began in the right cheek, subsequently 
involving the left ; perforation occurred in both cheeks, and before death 
a large part of the face was gangrenous. The odour from a severe case 
is very offensive, and, in spite of all efforts at disinfection, it may fill the 
ward or even the house. Pain is rarely severe, and in many cases it is 



absent. 



Extensive haemorrhages are rare. 



256 DISEASES OP THE DIGESTIVE SYSTEM. 

The usual duration of the disease is from three to seven days ; in some 
cases it may last two weeks. If recovery takes place, there is seen a line 
of demarcation ; then the slough is thrown off, and granulation and cica- 
trization begin, but require a long time, usually leaving an unsightly 
deformity. 

The prognosis is very bad, about three fourths of the cases proving 
fatal. The results depend not only upon the disease itself, but upon the 
condition of the patient with which it is associated. 

Gangrenous stomatitis can hardly be mistaken for any other form of 
disease occurring in the mouth, and early recognition is of great impor- 
tance, since only early treatment is likely to be successful. 

Treatment. — Much can be done to prevent the disease by careful 
attention to all the milder forms of stomatitis, particularly to the ulcera- 
tive variety. Frequent and thorough cleansing of the mouth in all acute 
infectious diseases, is a part of the treatment which is too frequently 
neglected. This should be a matter of routine in every severe illness in a 
young child. Recognising the malignant nature of gangrenous stoma- 
titis, its treatment should be radical from the very outset. Of the meas- 
ures which have been proposed, that which seems to offer the best chance 
of arresting the process is excision with cauterization. This should be 
done under anaesthesia. In excising, one should go some distance into 
tissues apparently healthy, for the reason that the process has always 
advanced farther in the subcutaneous tissues than in the skin. The edges 
of the wound should then be thoroughly cauterized, best by the Paquelin 
cautery. Of the other means employed, the use of strong nitric acid is 
probably the best. This is to be used after excising, or curetting the 
necrotic tissue. The mouth should be kept as clean as possible by the 
use of peroxide of hydrogen or permanganate of potash. The general 
treatment should be supporting and stimulating. As the possibility of 
contagion exists, every case should be isolated. 



CHAPTER II. 

DISEASES OF THE PHARYNX. 

ACUTE PHARYNGITIS. 

Acute pharyngitis may exist as a primary disease, or with any of the 
infectious diseases, particularly scarlet fever, measles, diphtheria, and 
influenza. Secondary pharyngitis will be considered in connection with 
these different diseases. 

Acute primary pharyngitis is often attributed to cold and exposure, 
but it is probable that a large number of these cases will ultimately be 



ACUTE PHARYNGITIS. 257 

shown to depend upon some form of infection. Certain children have a 
constitutional predisposition to attacks of pharyngitis, and contract it 
upon the slightest provocation. In some of them there is a strongly 
marked rheumatic diathesis. Attacks are frequently associated with dis- 
turbances of digestion. 

In acute catarrhal pharyngitis the inflammation may involve the en- 
tire mucous membrane of the tonsils, fauces, uvula, posterior and lateral 
pharyngeal walls, or any part of it. It may exist alone* or in connection 
with a similar inflammation in the rhino-pharynx or in the larynx. In 
the beginning there is seen an acute erythematous blush, usually involv- 
ing the entire pharynx. This may entirely subside after twenty-four 
hours, or it may be followed by the usual changes of acute catarrhal in- 
flammation — dryness, swelling, and oedema. Later there is increased 
secretion of mucus, and finally there may be muco-pus. Occasionally 
slight haemorrhages are present. 

There is pain at the angle of the jaws, which is increased by swallow- 
ing, a sensation of dryness and roughness in the pharynx, and often an 
irritating cough. There may be slight swelling of the neighbouring 
lymphatic glands. The constitutional symptoms in young children are 
often severe. Not infrequently there is a sudden onset with vomiting, 
and a rise of temperature to 103° or even 105° F. These symptoms are 
usually of short duration, frequently less than twenty-four hours, and in 
two or three days the patient may be quite well. In other cases the 
pharyngitis may be accompanied or followed by laryngitis. 

The chief point in diagnosis, when symptoms like the above are seen, 
is to exclude scarlet fever and measles. A positive diagnosis is impossible 
until a sufficient time has elapsed for the eruption to come out. The pa- 
tient should be closely watched for the first sign of its appearance. If scarlet 
fever is prevalent, a child with the symptoms of severe pharyngitis should 
at once be isolated while waiting for the diagnosis to be settled. There is 
commonly less difficulty in excluding measles, for in that disease the early 
redness is more upon the hard palate than upon the fauces, and usually 
consists of minute red spots rather than a uniform blush. There is, 
besides, a history of a previous catarrh for two or three days. 

The first step in treatment of acute pharyngitis is to open the bowels 
freely by means of calomel, castor oil, or magnesia. The child should be 
kept in bed, and the diet should be fluid, or, in the case of infants, the 
amount of food should be much reduced. Pieces of ice may be swallowed 
frequently for the relief of pain and thirst. Internally there may be given 
two grains of phenacetine every three hours to a child of three years. It 
is important at the outset to induce free perspiration. The disease is not 
serious, and the indications are to make the child as comfortable as pos- 
sible during the short attack. I have seen but little benefit from the 
use of aconite, although for years I saw it used as a routine treatment. 
22 



258 



DISEASES OF THE DIGESTIVE SYSTEM. 



UVUL1TIS. 



Acute inflammation of the uvula, with swelling and oedema, occurs as 
a part of the lesion in acute pharyngitis. In rare instances the uvula may 
be the principal or only seat of inflammation. Huber (New York) has 
reported two cases, one of which is unique. An infant ten months old 
was apparently well until two hours before it was seen, when there was 
Doticed a constant irritating cough, accompanied by considerable gagging. 
A little later there could be seen in the mouth a prominent red mass, 
which was the enlarged and elongated uvula. It was accompanied by 
paroxysms of cough, which interfered both with nursing and deglutition. 
The general symptoms were quite alarming, and the child was in con- 
siderable distress. On examination, the uvula was found to be fully one 
inch long and half an inch wide ; it was red and (Edematous ; in other 
respects, however, the throat was normal. The symptoms were relieved 
by multiple needle punctures and the use of ice externally and internally. 

ELONGATED UVULA. 

Probably this is primarily a congenital condition. It is increased by 
repeated attacks of acute or subacute inflammation. The degree of 
elongation differs very much in different cases ; in some it may reach an 
inch in length. According to Bosworth, only the mucous membrane is 
involved in the elongation. The symptoms are those of local irritation, 
especially a cough upon lying down, and the sensation of a foreign body 
in the pharynx. In some cases it may be a reflex cause of asthma, or, 
more frequently, of catarrhal spasm of the larynx. The diagnosis is very 
easily made by inspecting the throat. The treatment consists in grasping 
the tip of the uvula with forceps and cutting off the excess with the 
scissors, or a uvulatome. Care should be taken not to cut off too much 
of the uvula, or severe haemorrhage may occur. 

RETRO-PHARYNGEAL ABSCESS. 

Two distinct varieties are seen : (1) the so-called idiopathic abscesses 
which belong to infancy, and (2) abscesses secondary to caries of the cer- 
vical vertebras. 

Ketro-pharyngeal Abscess of Infancy. — All of the later investigations 
regarding this disease go to show that primarily it is not a cellulitis, but a 
suppurative inflammation of the lymph nodes (lymphatic glands) with a 
surrounding cellulitis. Jules Simon has described the retro-pharyngeal 
lymph nodes as forming a chain on either side of the median line between 
the pharyngeal and the prevertebral muscles. These nodes are said to 
undergo atrophy after the third year, and in some cases to disappear 
entirely. Ketro-pharyngeal abscess — or more properly retro-pharyngeal 



RETRO-PHARYNGEAL ABSCESS. 259 

adenitis, since the process does not invariably go on to suppuration — is 
probably never primary, but secondary to infectious catarrhs of the phar- 
ynx, and is set up by the entrance of pyogenic bacteria. Its pathology is 
the same as the more frequent suppurative inflammation of the external 
cervical lymph nodes, with which it is sometimes associated. Usually only 
a single node is involved, but sometimes two or three are affected, and 
these may be situated upon opposite sides. I have seen retro-pharyngeal 
adenitis so severe as to give rise to marked local symptoms, although it 
did not go on to suppuration. This is rare; Kormann's observations, 
however, show that swelling of these glands in diseases of the mouth and 
throat, is very much more common than is generally supposed. Similar 
abscesses from suppurative inflammation of other lymph nodes in the 
neighbourhood of the pharynx may occur. I have recently seen one situ- 
ated between the epiglottis and the base of the tongue. 

Etiology. — These cases are almost invariably seen in infancy. Fully 
three fourths of those that have come under my observation have been in 
patients under one year. Bokai (Buda-Pesth) reports that of sixty cases 
observed, forty-two occurred during the first year, eleven during the sec- 
ond year, and only seven at a later period. The primary disease is usually 
a severe rhino-pharyngitis, or an attack of epidemic influenza, but rarely 
it occurs as a sequel of scarlet fever or measles. In six hundred and sixty- 
four cases of scarlet fever, Bokai noted retro-pharyngeal abscess in seven 
cases. After measles it is even more rare. Eetro-pharyngeal abscess usu- 
ally occurs in winter or spring, on account of the prevalence of the dis- 
eases upon which it depends. It is seen in children previously robust, but 
more often in those who are delicate and who in consequence are prone to 
severe catarrhal affections. 

Symptoms. — The early symptoms in most cases are only those of an 
ordinary rhino-pharyngeal catarrh. After this has subsided the tempera- 
ture may remain slightly elevated, often for a week or more, before local 
symptoms are noticeable. Sometimes, without any distinct history of pre- 
vious catarrh, there are seen quite high temperature, from 102° to 104° F., 
loss of flesh, and prostration. A careful examination may be required, and 
sometimes observation for a day or two, before the explanation of these 
constitutional symptoms is discovered. In other cases the early consti- 
tutional symptoms are so slight as to escape notice, and the physician is 
summoned on account of the local symptoms, usually the dyspnoea, which 
in a short time may assume an alarming character. The duration of the 
inflammatory process before abscess forms is generally five or six days, but 
it may be two or three weeks. The temperature is invariably elevated, 
usually from 100° to 103° F. ; occasionally it may be 104° or 105° F., with 
symptoms of prostration seemingly out of all proportion to the local dis- 
ease, but which are to be explained by the tender age and feeble resistance 
of the patient. 



260 DISEASES OP THE DIGESTIVE SYSTEM. 

The first local symptom may be a sudden attack of dyspnoea severe 
enough to cause asphyxia. This is due to the pressure forward of the ab- 
scess which encroaches upon the opening of the larynx. Usually before 
this occurs the breathing is noisy, especially during sleep, and on account 
of the obstruction to nasal respiration the patient breathes with the mouth 
open. This causes dryness of the mouth, and adds greatly to the child's 
discomfort. The dyspnoea is in most cases greater on inspiration, and in 
some it is noticed only then, expiration being normal. The dyspnoea is 
sometimes increased by attempts at swallowing. The degree to which 
deglutition is interfered with depends upon the size and the position of 
the tumour. It is more difficult when the tumour is low down. The 
child may find it impossible to swallow, and in consequence may refuse to 
nurse ; or the difficulty in nursing may depend upon the nasal obstruc- 
tion. Sometimes there is regurgitation of food through the nose or 
mouth. The voice is usually nasal. There is not generally hoarseness, 
but a peculiar short cry which is quite characteristic and which has been 
compared to the " quack " of a duck. There may be complete aphonia ; 
often there is a short, dry cough. In most of the cases a tumour is to be 
seen externally, just below the angle of the jaw and in front of the sterno- 
mastoid muscle. It is rarely so large as to attract attention. The head 
is thrown back in order to relieve the pressure upon the larynx, and is held 
somewhat rigidly. In one or two cases I have noticed torticollis as an 
early symptom. 

A positive diagnosis is made by an examination of the throat. On in- 
spection there is seen a distinct bulging of the lateral wall of the pharynx, 
usually a little above the base of the tongue. The swelling may be so 
great as to crowd the uvula to one side and nearly fill the pharynx. It is 
rarely if ever in the median line. There is usually redness of the mucous 
membrane and oedema of the uvula and of the adjacent parts. On digital 
examination the swelling is made out even better than by inspection. If 
it is lower down it may not be visible at all. In the early stage there may 
be felt only a localized induration or a somewhat diffuse swelling, but by 
the time the swelling is large enough to produce marked symptoms, fluc- 
tuation can generally be discovered. 

Prognosis.— When left to itself the abscess usually opens into the phar- 
ynx, the pus being swallowed or expectorated. The cavity closes rapidly 
by granulation, and the patient in a few days is entirely well. It is rare 
for much burrowing to occur. In young or very delicate infants the con- 
stitutional symptoms may be so severe that the child continues to fail 
even after the evacuation of the abscess, and, gradually sinking, dies from 
marasmus or broncho-pneumonia. In other children a fatal result is gen- 
erally due to the fact that the disease is not recognised. 

Death before rupture may occur from asphyxia due to pressure upon 
the larynx or oedema of the larynx, or to rupture of the abscess into the 



RETRO-PHARYNGEAL ABSCESS. 261 

air passages, especially if this occurs during sleep. Carmichael, Bokai, 
and others have reported deaths from ulceration into the carotid artery or 
one of its large branches. Oarmichael's patient was only five weeks old. 
The general mortality of the disease is about five per cent ; most of the 
deaths are owing to a failure to make the diagnosis. Gautier has col- 
lected ninety-five cases, with forty-one deaths. I have never seen a fatal 
termination, although in several cases most alarming symptoms were 
present. 

Diagnosis. — Retro-pharyngeal abscess is to be suspected if there is dif- 
ficulty in swallowing associated with dyspnoea or mouth-breathing. A 
positive diagnosis is possible only by a digital examination of the pharynx. 
The mistake most often made in diagnosis has been, that the physician, 
called to a young child suffering from great dyspnoea, has jumped to the 
diagnosis of laryngeal stenosis, and forthwith performed tracheotomy or 
intubation, without taking the trouble to get the history or to make a 
careful examination of the pharynx. Many such cases are reported in 
which the child has died during the operation or immediately afterward, 
the autopsy first revealing the nature of the disease. If the possibility of 
this mistake is kept in mind, the error can hardly be made. A sudden 
attack of dyspnoea with difficulty in swallowing may also be due to the 
impaction of a foreign body in the pharynx ; but a digital examination in 
this case will enable one to make a correct diagnosis. 

Treatment. — Before the abscess has pointed, hot applications should be 
made to the throat to relieve the symptoms and to hasten the formation 
of pus, since resolution is so rare as not to be expected. Spontaneous 
opening should never be waited for, on account of the danger of the rapid 
development of serious symptoms from pressure or oedema, or of suffoca- 
tion from an opening into the air passages, especially during sleep. 

As soon as the diagnosis is made the case should be carefully watched, 
and as soon as well-marked fluctuation is detected, the pus should be evac- 
uated. External incision has no advantages and has very obvious objec- 
tions. In opening through the mouth the patient should be seated in an 
upright position and the head firmly held. A gag should not be intro- 
duced, but a tongue depressor may be used, and a bistoury which has been 
guarded to its point plunged into the abscess at its thinnest point and the 
incision made toward the median line. The head should then be bent for- 
ward, to allow the pus to escape through the mouth. It is well to insert 
the finger into the cavity and break down any septa; for after a simple 
puncture the abscess may refill. Incision, although usually easy, in some 
cases may be quite difficult on account of the swelling and the small 
pharynx of the infant. For the past few years I have adopted the plan 
of opening these abscesses with the finger nail, a procedure simple, effi- 
cient, and free from danger. While the patient is held as above described, 
the wall of the abscess is perforated by the nail of the forefinger, which 



262 DISEASES OP THE DIGESTIVE SYSTEM. 

has been sharpened to a cutting point. I have yet to see a case in which 
this was at all difficult. The amount of pus evacuated is from one 
drachm to half an ounce. In the majority of cases no after-treatment is 
required. The relief of the dyspnoea and dysphagia is immediate, and re- 
covery rapid. 

An instructive accident, which came near being fatal, occurred in a case 
at the New York Infant Asylum. An infant seven months old had shown 
for twenty-four hours stertorous breathing, difficulty in swallowing, and 
had refused to nurse. Examination showed the presence of quite a large 
abscess in the right pharyngeal region. A gag was introduced by the 
house surgeon preparatory to the evacuation of the abscess by incision, 
when the child became asphyxiated, and respiration ceased although the 
gag was immediately removed. Intubation was performed, but with a 
good deal of difficulty on account of the displacement of the larynx, 
and artificial respiration was required for several minutes before the 
patient was resuscitated. The abscess was incised half an hour later 
without the introduction of a gag, and the intubation tube removed. 
The attack of asphyxia was evidently produced by the stretching of the 
mouth by the gag, and the increased pressure thereby produced upon the 
larynx. 

Betro-pharyngeal Abscess from Pott's Disease. — This form is rare in 
comparison with that just described, and under three years of age it is 
extremely so. These abscesses are usually larger, and the amount of pus 
contained may be from four to eight ounces. They form very much more 
slowly, often lasting for months, and, like other secondary abscesses, the 
constitutional symptoms are seldom severe. The swelling- is frequently 
in the median line, and is. not so circumscribed as in the idiopathic cases. 
The pus often burrows along the spine for several inches. 

The symptoms of Pott's disease of the cervical region are usually pres- 
ent for several months before the appearance of the abscess. Sometimes 
the abscess precedes the deformity, and it may be the first intimation of 
the existence of bone disease. The local symptoms resemble those of the 
idiopathic cases, but they develop more slowly, and sudden attacks of 
fatal asphyxia are very rare. External swelling is usually seen, and it 
may be quite large, extending almost from one ear to the other, forming a 
distinct collar. On digital exploration there may be found an irregularity 
of the anterior surfaces of the cervical vertebrae, and occasionally a marked 
angular prominence. 

When left to themselves these abscesses may open externally in front 
of the sterno-mastoid muscle, just below the jaw, sometimes nearly as low 
as the clavicle ; they may rupture internally into the pharynx, the oesopha- 
gus, or the air passages ; or they may burrow a long distance in front of the 
spine. Death may result from pressure upon the larynx, or from rupture 
into the larynx, trachea, or pleura; all these, however, are rare. The 






ADENOID VEGETATIONS. 263 

abscesses not infrequently refill after they are evacuated, and occasionally 
a discharging sinus is left for many months. 

Treatment. — These abscesses should be opened as soon as they are 
large enough to give rise to local symptoms. The external incision just 
in front of the sterno-mastoid muscle is generally to be preferred to 
opening through the mouth, since it gives better drainage, and the after- 
treatment is more easily carried on ; and a sinus opening externally is less 
objectionable than one opening into the pharynx. 

ADENOID VEGETATIONS OF THE VAULT OF THE PHARYNX. 

This is a very common and, by the general practitioner, a much neg- 
lected condition. It is the source of more discomfort and the origin of 
more minor ailments than almost any other pathological condition of 
childhood. 

"There is a mass of lymphoid tissue situated at the vault of the pharynx 
which in structure closely resembles the tonsils. It is often spoken of as 
the " pharyngeal tonsil." Like the faucial tonsils, and under similar con- 
ditions, this may become greatly hypertrophied, so as to form a tumour, 
which may be so large as to fill the rhino-pharynx completely. These 
tumours have a broad base, and are attached sometimes more to the roof, 
and sometimes more to the posterior wall of the pharynx. The term 
adenoid vegetations was given to them by Meyer, who first described 
them in 1868. These growths may be soft, vascular, and spongy, or hard, 
firm, and fibrous. The first variety is that usually seen in infancy, and 
the second more often in older children. In a very considerable propor- 
tion of the cases there is associated hypertrophy of the tonsils. As a re- 
sult of the growth there is sometimes present a very high palatine arch 
amounting almost to deformity. 

Etiology. — That condition spoken of in another chapter as the lym- 
phatic diathesis, or " lymphatism," is the one upon which these growths 
most frequently depend. Often every member of a large family of chil- 
dren is affected, and frequently both parents also. This may occur 
when there are no other evidences of disease except this tendency. Deli- 
cate and rachitic children are, however, more prone than others to this 
affection. It is most common in damp, changeable climates. The first 
symptoms usually follow an attack of influenza, measles, scarlet fever, 
diphtheria, or repeated attacks of ordinary coryza. They generally begin 
to be troublesome when children are about two years old ; there are 
many cases, however, in which it seems pretty clear that the condition is 
a congenital one. Many observers hold this view regarding most of the 
cases. 

Symptoms. — The symptoms of adenoid growths are those which relate 
to the chronic rhino-pharyngeal catarrh and to the mechanical obstruc- 
tion. In infants and very young children the catarrhal Bymptoms are 



264 DISEASES OF THE DIGESTIVE SYSTEM. 

apt to predominate; in older children, the obstructive symptoms. The 
chronic catarrh shows itself by a persistent nasal discharge, which is of a 
sero-mucous or muco-purulent character, very rarely tinged with blood. 
This may be continuous, with exacerbations which occur with every fresh 
cold and with every period of damp weather, or there may be intervals in 
which the symptoms are absent. In dry weather and in summer the dis- 
charge usually ceases entirely, coming on again when the damp weather 
of autumn and winter returns. This is the condition which underlies the 
repeated severe head-colds from which so many children suffer every cold 
season. The symptoms of obstruction are mouth-breathing, nasal voice, 
and difficulty in blowing the nose, sometimes total inability to do so. The 
mouth-breathing may be constant, or it may be noticed only during sleep, 
being accompanied by loud, stertorous respiration. The difficulty in 
breathing is increased when the child lies upon the back. In consequence 
of this, children sleep in all sorts of positions — lying upon the face, some- 
times upon the hands and knees, and often toss restlessly about the crib 
in the vain endeavour to find some position in which respiration is easy. 
Such symptoms should always arouse suspicion of a lymphoid growth in 
the pharynx. In a case under recent observation the attacks of dyspnoea 
at night amounted almost to complete asphyxia. The child would rise 
upon the hands and knees and struggle violently for breath, often without 
waking; sometimes respiration would cease for several seconds, and he 
would awake exhausted and covered with perspiration. The mucus and 
saliva were drawn back and forth until the lips and mouth were covered 
with a white foam. During the day the symptoms of obstruction may 
scarcely be noticed. The continued inability to blow the nose, if asso- 
ciated with nasal discharge, should always be regarded as a suspicious 
symptom. In several cases this has been the first symptom noticed. 

Two other symptoms are common in very young children — frequent 
attacks of otitis and persistent hoarseness or huskiness of voice which 
may lead to the suspicion that the larynx is the seat of the disease. 

In older children and in neglected cases the symptoms are often more 
marked. The patients are mouth-breathers, both by day and night. The 
expression of the face is dull, stupid, often semi-idiotic (Fig. 46). Sleep 
is never deep, and is always accompanied with stertorous respiration and 
constant tossing from side to side. The voice is thick, nasal, and 
" wooden." In severe cases nervous symptoms of quite a serious character 
may be present. The children are languid, listless, sometimes depressed 
and prone to melancholy, suffering from frequent headaches and from 
attacks of indisposition, and often passing for very stupid children. 

The hearing is impaired in a very large number of the cases. Blake 
(Boston) found this true of thirty-nine out of forty-seven cases examined, 
:u id in thirty-five of these marked improvement in hearing followed 
operation upon the growths. Deafness may be due to mechanical causes, 



ADENOID VEGETATIONS. 



265 



or to otitis. "Where the condition has existed from infancy there is often 
marked deformity of the chest. There may be simply a marked pigeon- 
breast and prominent sternum with deep lateral depressions (Fig. 45), or 
there may be a deep depression over the lower portion of the sternum. 
Deformities are most marked in rachitic patients. These growths often 
produce anaemia and general malnutrition owing to the constant interfer- 
ence with sleep and obstruction to respiration, and they may be a reflex 
cause of many neuroses, such as chorea, incontinence of urine, asthma, 
catarrhal spasm of the larynx, and sometimes even epileptiform seizures. 




v ; 





Fig. 45. — Pigeon-breast due to adenoids of the pharynx. 

These patients are always better in summer and worse in winter. 
The natural course of the growths if left to themselves is to increase up 
to a certain point and then to remain stationary until puberty. After 
this time they usually undergo atrophy, and the small ones may disap- 
pear entirely. In the more severe cases the symptoms persist, aggravated 
from time to time during attacks of acute catarrh. A removal fco an ele- 
vated region with a dry atmosphere will often result in a disappearance of 
all the symptoms, and the growth may cease to increase in size, bul anlosa 
such a change in residence is permanent the symptoms are liable to re- 



266 DISEASES OF THE DIGESTIVE SYSTEM. 

turn. Under ordinary circumstances there is little or no tendency to 
spontaneous recovery. Patients with adenoid growths contract diphtheria 
more easily than do others, and in them attacks of diphtheria, scarlet 
fever, measles, and whooping-cough are all likely to be more severe. 

Diagnosis. — In a well-marked case the condition is usually evident from 
the history, and can scarcely be overlooked. The intractable nasal ca- 
tarrh, upon which no treatment, local or general, has more than a tem- 
porary influence, the mouth -breathing, the disturbed sleep, and the slight 
deafness — all are characteristic. In some even of the marked cases atten- 
tion may be drawn to the larynx or to the ears as the seat of disease. At 
other times the patients come for treatment on account of the general 
symptoms — the nervous depression, the headaches, or the anaemia. In 
rare cases the leading symptom may be epistaxis. The symptoms do not 
always depend upon the size of the growth, for in a small cavity quite a 
small growth may cause very marked symptoms. 

Although the history is in most cases clear, only an examination can 
make us certain that a lymphoid growth exists. The best method of ex- 
amination consists in a digital exploration of the pharynx; but this 
requires a little practice before it is very satisfactory. The head is stead- 
ied by the right hand, and the left forefinger is passed up behind the pal- 
ate. The growth is ordinarily felt as an irregular, soft, velvety mass, and 
the finger, when withdrawn, is almost invariably covered with blood. The 
physician must make his diagnosis by the first examination, as the child 
will allow no repetition. By anterior rhinoscopy, after the use of cocaine, 
the growth can usually be seen distinctly. 

Treatment. — Absorption by internal medication is possible in but few 
cases. Bosworth reports the best results from the syrup of the iodide of 
iron, which must be given in doses of from ten to fifteen drops three times 
a day for a long period. This should be combined with cold sponging 
and general precautions to prevent a recurrence of colds, and, if possible, 
the child should pass the winter in a warm, dry climate. These measures 
may succeed when the growths are small, and where the symptoms are 
more catarrhal than obstructive. In larger growths and in cases of longer 
standing, only temporary improvement is likely to follow such treatment. 
An attempt to reduce by local application, growths of any considerable 
size, is a waste of time and not to be recommended. My experience has 
been that, in spite of prolonged local treatment, every marked case has 
ultimately required operation. 

Operation during the spring or summer is generally preferable, but 
may be performed at any time except during attacks of acute catarrh. 
Some very expert operators prefer to do without an anaesthetic, and no 
doubt there are a few of large experience who can operate satisfactorily in 
most of the cases without anaesthesia. Under ordinary circumstances, 
however, complete anaesthesia is to be preferred, and by chloroform rather 



ADENOID VEGETATIONS OF THE PHARYNX. 267 

than ether. An exception should be made of cases where the growths are 
small, soft, and very spongy. These may often be rubbed off with the 
pulp of the finger or scraped away by the finger nail, without giving the 
patient or friends any idea that an operation has been done ; and this can 
frequently be accomplished under the plea of simply making a digital 
examination. 

The instruments required are Lowenberg's cutting forceps, Gott- 
stein's curette, and a mouth-gag like that used for intubation. After full 
anaesthesia is reached, the gag is introduced and the soft palate drawn for- 
ward by a blunt hook of hard rubber, or, better, by the forefinger of the 
left hand, which at the same time acts as a guide to the introduction of 
the forceps. These are introduced closed and passed up along the poste- 




X 







Figs. 46 



Before operation. Three months after operation, 

and 47. — Adenoid vegetations of the pharynx ; girl twelve years old. (Hooper.) 

rior pharyngeal wall, and the mass seized and torn away piecemeal. The 
first bite of the forceps will often bring away the greater part of the 
growth when it is of small size ; if large, ten or fifteen repetitions may be 
necessary. After the greater part has been removed by the forceps the 
curette is introduced and the pharyngeal vault scraped clean. In a large 
number of the cases with growths of small or moderate size, the entire 
mass may be removed by one, or at most two, applications of the curette, 
without previously using the forceps. This has the advantage that it can 
be done much more quickly. In most cases the entire operation does not 
consume more than two or three minutes. The child is turned upon his 
face, in order that the blood, which flows freely, may escape from the 
mouth and nose. The head should be kept low during the operation, to 
prevent the blood from entering the larynx. Hooper and sonic other 
writers prefer to operate with the patient in the sitting posture. Each 
position has its advantages. 



268 DISEASES OP THE DIGESTIVE SYSTEM. 

The dangers of operation are practically none. Excessive haemorrhage 
is extremely rare, although there are two or three recorded cases in which 
serious and even fatal haemorrhage occurred. Attacks of acute tonsillitis 
or otitis occasionally develop after operation. No after-treatment is 
necessary. The patient remains in bed during the day of operation, and 
in the house for three or four days, or longer if the weather is unpleasant. 
No local applications are required. It is probably not necessary that 
every particle of the growth should be removed, since if the major part is 
taken away, what remains generally undergoes rapid atrophy. A recur- 
rence of the growths is very rare. 

The improvement after the operation is in proportion to the severity 
of the previous symptoms. The respiration is freer ; the sleep becomes 
quiet ; the mouth is soon habitually closed ; the voice improves ; and the 
benefit to the general health is in a short time apparent. The whole ap- 
pearance of the child is often transformed in a few months (Figs. 46 and 
47). 



CHAPTER III. 

DISEASES OF TEE TONSILS. 

The tonsils* are lymphoid structures closely resembling Peyer's 
patches, but, instead of having a flattened surface, the lymphoid tissue in 
the tonsil is folded upon itself, forming quite deep depressions — the ton- 
sillar crypts. These crypts, like the surface of the tonsils, are lined by 
epithelial cells. They contain lymphoid cells, desquamated epithelium, 
particles of food, and bacteria. Under normal conditions the tonsils 
take no part in absorption from the mouth. When, however, their epi- 
thelium is rarefied or removed, the tonsils absorb with very great facility 
every sort of poison which the mouth may contain. Such poisons are 
taken up by the lymphatics, and through them reach the general circu- 
lation. 

Acute inflammation of the tonsils, like that of the pharynx, occurs 
regularly in diphtheria, scarlet fever, and measles, less frequently in the 
other infectious diseases. The secondary forms will be considered with 
the diseases with which they are associated. 

Acute catarrhal tonsillitis, or inflammation of the mucous membrane 
covering the tonsils, occurs as a primary disease as a part of the lesion in 
acute pharyngitis, but very rarely is seen alone. Occasionally the whole 
mucous membrane covering the tonsils is inflamed and fibrin may be 

* For a critical study of the anatomy and physiology of the tonsil, see paper by 
Hodenpyl, American Journal of the Medical Sciences, March, 1891. 



FOLLICULAR TONSILLITIS. 269 

poured out in sufficient quantity to form a distinct pseudo-membrane. 
These cases, formerly classed as " croupous tonsillitis," will be considered 
elsewhere under the head of Pseudo-diphtheria. 

FOLLICULAR TONSILLITIS. 

This is the most frequent and most characteristic form of inflamma- 
tion of the tonsil. It is essentially an inflammation of the tonsillar 
crypts, and secondarily of the whole glandular structure. 

Etiology. — There is seen in certain children a predisposition to attacks 
of tonsillitis, so that from very slight exciting causes these occur, some- 
times traceable to exposure, sometimes to derangement of the stomach, 
and sometimes without any evident reason. Children with a rheumatic 
inheritance appear to be more susceptible than others. One attack pre- 
disposes to a second. Patients suffering from chronic hypertrophy of the 
tonsils are exceedingly prone to acute tonsillitis. It is not very common 
in infancy, but after this period it is very frequent throughout childhood. 
The disease, in all probability, begins as an infectious inflammation at the 
bottom of the crypts, due to the presence of streptococci or staphylococci, 
which readily enter from the mouth, and excite an attack whenever favour- 
able conditions are present. 

Lesions. — As a result of the inflammation, the tonsillar crypts are 
filled with epithelial cells, pus cells, mucus, and bacteria. These form 
masses which appear at the mouth of the crypts as small yellow dots, 
often miscalled ulcers. Sometimes, in addition, fibrin is poured out, and 
forms, with the other inflammatory products, little plugs which project 
somewhat from the surface of the mucous membrane, and which can 
easily be pressed out. Accompanying the changes in the mucous mem- 
brane above mentioned, there are acute congestion and swelling of the 
whole tonsil, with more or less proliferation of the lymphoid tissue. Fol- 
licular tonsillitis is always bilateral. Although the pathological process is 
generally limited to the tonsils, there may be more or less pharyngitis 
associated. 

Symptoms. — The general symptoms usually appear before the local 
ones, and are often quite severe. The onset is abrupt, with chilly sensa- 
tions, occasionally a distinct rigour. In infants there is often vomiting, 
and sometimes diarrhoea. There is pain in the back, in the muscles of 
the extremities, and in the head. Sometimes there is pain in the lateral 
cervical muscles. The temperature rises rapidly to 102° or 103° P. ; often 
it touches 104° or 105° F. 

The first local symptoms are some swelling of the tonsils and the ap- 
pearance of isolated yellow spots a little larger than a pin's head. Often 
these can be wiped off with a swab, or the little plugs can !>«• squeezed 
out, leaving a slight depression.. Later there is acute congestion of the 
tonsil, with more swelling. Even when the disease ie al its height the 



270 DISEASES OF THE DIGESTIVE SYSTEM. 

local pain and discomfort are only moderate, and in many cases scarcely 
noticeable. The swelling and tenderness of the lymph glands behind the 
angle of the jaw are not great, and may be absent. 

The constitutional symptoms, as a rule, last three days, and are most 
severe upon the first day. The local symptoms last somewhat longer, but 
usually by the end of the fourth day the exudate has disappeared, although 
enlargement of the tonsil may persist for a week or even longer. 

Diagnosis. — Tonsillitis may be confounded at its onset with scarlet 
fever. We must wait for the rash before deciding positively. Its consti- 
tutional symptoms in the beginning closely resemble an attack of malaria, 
influenza, or pneumonia. The great frequency of tonsillitis makes inspec- 
tion of the throat imperative in every case of acute illness in children. 
The diagnosis from diphtheria is considered in connection with that 
disease. 

Treatment. — Follicular tonsillitis is a mild disease without danger to 
life, and one which runs a short, self-limited course. The indications are, 
therefore, to make the patient as comfortable as possible by the relief of 
individual symptoms. Older children, particularly those who are rheu- 
matic, should be treated with salol ; four grains every three hours being 
given for the first twenty-four hours, and later smaller doses. In infants 
this drug is somewhat difficult of administration on account of its tend- 
ency to upset the stomach, and had better be omitted. The general 
aching pains of the first day are best relieved by phenacetine, two grains 
every three hours to a child three years old. Later it may be used in 
smaller doses, but enough should be given to make the patient com- 
fortable. 

Local treatment is not absolutely necessary, and in infants may be 
omitted. Older children may use a gargle of boric acid or a weak bichlo- 
ride solution — i. e., 1 to 10,000. In all doubtful cases the patient should 
be isolated, and the same treatment adopted as in a case of diphtheria, 
until all doubt is removed. 

PHLEGMONOUS TONSILLITIS— PERITONSILLAR ABSCESS— QUINSY. 

This is an inflammation of the cellular tissue surrounding the tonsil, 
sometimes invading the tonsil itself. It may terminate in resolution, but 
usually goes on to the formation of an abscess. Phlegmonous tonsillitis is 
much less common in children than in adults, and, compared with the 
other forms, it is a rare disease in early life. It is the only variety which 
is regularly unilateral. In most cases the inflammatory process is circum- 
scribed, but in rare instances there is seen a diffuse phlegmonous inflam- 
mation of the pharynx. 

In certain patients there exists a constitutional predisposition to the 
disease, which is often associated with rheumatism. The exciting causes 
may be exposure, or anything which may reduce the patient's general 






PHLEGMONOUS TONSILLITIS. 271 

health, to which there is added local infection. Catarrhal pharyngitis 
predisposes to this disease. 

Symptoms. — The onset resembles that of follicular tonsillitis, except 
that the general symptoms are usually less marked, the temperature is 
commonly not so high, and the aching pains and prostration less severe. 
The local symptoms, however, are more marked. There is very severe 
pain in the throat, which is increased by deglutition, and finally may be 
so great that swallowing is almost impossible. It is difficult to open the 
mouth. There is pain in the lateral muscles of the neck, and often ten- 
derness. In the beginning but little can be seen on inspection, even 
though the patient complains of a very sore throat. This is always a 
suspicious circumstance, and should lead one to look out for quinsy. It is 
due to the fact that the inflammation begins in the deeper tissues, and that 
the mucous membrane is affected later. After twenty-four or forty-eight 
hours there is usually quite marked swelling, which is rather more behind 
the tonsil than elsewhere, pushing it upward and forward ; sometimes 
it is more in front of the tonsil. A little later there is intense inflamma- 
tion of the mucous membrane covering the tonsil, fauces, and uvula, with 
marked congestion and oedema ; the uvula may be pushed to one side, and 
the isthmus of the fauces diminished to less than one half its natural size. 
In one of my own cases marked torticollis was present, and existed for 
two or three days before the diagnosis of quinsy could be made by the 
other symptoms. 

In most cases the recognition of quinsy is quite easy by attention to the 
symptoms above mentioned. By inspection of the throat, less information 
is sometimes obtained than by palpation ; by this means a fulness, and 
later a point of fluctuation, can readily be made out. Acute phlegmonous 
tonsillitis generally involves no danger to life. In very young infants 
serious results may follow spontaneous rupture during sleep ; and in 
older children occasionally there may be oedema of the glottis. If not 
treated, abscess usually forms in from five to seven days, and opens spon- 
taneously. 

Treatment. — If an early diagnosis is made an attack of quinsy may 
occasionally be aborted. For this many drugs have been advocated, but 
to my mind the best is salol, which should be given in doses of two 
grains every two hours to a child of five years. In some patients larger 
doses may be used. This may be combined with small doses (gr. ■}) of 
Dover's powder. Belief may be afforded by very hot or cold applications, 
according to the sensations of the patient. The holding of ice in the 
mouth and the application of an ice-bag externally, often give great com- 
fort. In other cases, gargling with very hot water and the application of 
hot flaxseed poultices externally, will be preferred. As soon as fluctuation 
is detected an incision should be made with a guarded bistoury. If made 
too early, only a small amount of pus is evacuated and the abscess may 



272 DISEASES OP THE DIGESTIVE SYSTEM. 

refill. After- spontaneous rupture the relief to symptoms is usually im- 
mediate. 

CHRONIC HYPERTROPHY OF THE TONSILS.— CHRONIC TONSILLITIS. 

The condition known as chronic hypertrophy, is a permanent enlarge- 
ment due to a proliferation of the lymphoid tissue of the tonsils, and an 
increase in the connective-tissue stroma. If the increase in the connective 
tissue is slight, the tonsil is soft ; if it is great, the tonsil is firm and hard, 
almost like a fibrous tumour. All degrees are found. Associated with 
hypertrophy of the tonsils there are frequently found adenoid growths of 
the pharynx, both of these depending upon similar local and constitu- 
tional conditions. There is in nearly all marked cases a chronic pharyn- 
geal catarrh which may involve the Eustachian tubes. 

Etiology. — Hypertrophy of the tonsils is an exceedingly common con- 
dition in the cities of the seacoast and lake districts of the temperate 
zone. In a routine examination of 2,000 New York school children, 
Chappell found enlargement of the tonsils sufficiently marked to be con- 
sidered pathological, in 270 cases. The causes are constitutional and local. 
The constitutional causes relate to the conditions described in the chapter 
upon Lymphatism. This is often found in certain families for several 
generations. The condition is not connected with tuberculosis. It oc- 
curs in children who are in other respects healthy. Hypertrophy of the 
tonsils is often a congenital condition, increasing slowly during infancy, 
so as to produce marked symptoms by the time the child is two years old. 
The most important of the local causes are attacks of acute or subacute 
pharyngitis. While it is true that attacks of acute inflammation are often 
the cause of hypertrophy, it is also true that hypertrophy is one of the 
most frequent predisposing causes of acute attacks, and that it may be 
seen in children who have never had tonsillitis. 

Symptoms. — Hypertrophy of the tonsils is rarely marked enough to 
cause any decided symptoms before the end of the second year, although 
I once saw in a younger child enlargement sufficient to bring the two ton- 
sils into contact. The most important local symptoms, formerly ascribed 
to hypertrophied tonsils, are now known to depend upon adenoid growths 
of the pharynx. As these conditions are so frequently associated, it is 
somewhat difficult to determine which symptoms are due to the tonsils 
alone. In a marked case, the most prominent symptoms are mouth- 
breathing, disturbed sleep accompanied by snoring, and nasal voice — the 
patient in some cases talking as though he had food in his mouth. There 
may be some difficulty in swallowing solid food. Enlarged tonsils may 
often be felt externally. As a consequence of the obstruction of the 
Eustachian tubes there may be deafness. Deformities of the chest, such 
as pigeon-breast, are occasionally seen, but probably depend more upon 
obstructed respiration by adenoids than by the tonsils. 



CHRONIC HYPERTROPHY OF THE TONSILS. 273 

The soft tonsils may diminish somewhat in size spontaneously. They 
sometimes shrink very decidedly after an attack of acute tonsillitis, scarlet 
fever, or diphtheria. As a rule the tonsils become firmer and harder 
as time passes. They usually increase in size up to a certain point, 
and then remain nearly stationary until about puberty, when they may 
diminish considerably. During intercurrent attacks of inflammation, the 
swelling is much increased and the symptoms are proportionately aggra- 
vated. Id cases of marked enlargement very little spontaneous improve- 
ment is to be looked for during childhood. 

Treatment. — Very large tonsils are a source of continued danger to the 
patient, and in every case of marked hypertrophy treatment should be 
advised. The danger may be from Eustachian catarrh and deafness, or 
from repeated attacks of acute tonsillitis. But even more important than 
these is the fact that they increase the liability to contract diphtheria, and 
add to the dangers both of diphtheria and scarlet fever. If the patient is 
removed from the locality in which acute tonsillitis is likely to occur, to a 
high, dry climate, considerable improvement is likely to result in a young 
child in whom the tonsils are soft, but not much is to be expected in 
older children with hard, fibrous tonsils, except, perhaps a cure of the 
accompanying pharyngeal catarrh. 

The only internal remedy offering much chance of benefit is, in my 
experience, the syrup of the iodide of iron, wmich must be given in quite 
large doses (twenty drops three times a day to a child of five years), and 
continued for several months. In a small number of cases marked im- 
provement is seen from this treatment, but in the majority but little 
change occurs. Astringent applications may accomplish something in 
recent, but practically nothing in old cases. In a marked case, operation 
is the only thing which can be relied upon to effect a cure. In those in 
which it is decided not to operate, or in which operation is refused, a 
faithful trial may be made with the other measures referred to. The 
question to be decided always is whether or not operation shall be done. 
For convenience of consideration, the cases may be divided into three 
groups: (1) those in which the tonsils are nearly or quite in contact ;(2) 
those in which they project not more than one fourth of an inch beyond 
the faucial pillars; (3) the intermediate cases. All of the first group 
should unquestionably be operated upon, unless the patient's general con- 
dition is such as to forbid operation of any kind. Of the second group, 
few if any require operation. Whether an operation is done in the third 
group will depend upon the individual case. If there are frequent attacks 
of acute tonsillitis, and some deafness, an operation should be performed. 
If little or no local discomfort is experienced it may be postponed. 

Of the i "ious operations proposed, excision with the guillotine is the 
one whic 1 in children superseded all others in the practice of New 

York r s. The risk of haemorrhage at this age is very slight. 



274 DISEASES OP THE DIGESTIVE SYSTEM. 

The child is held as for the operation of intubation, except that the head 
is thrown backward. No after-treatment is required, excepting fluid diet 
and confinement to the house for two or three days. Excessive haemor- 
rhage may be controlled by digital pressure, or by the application of 
styptic cotton upon a swab ; in extreme cases, by transfixing the tonsil 
stump with a hare-lip pin and the application of a ligature. I have more 
than once seen physicians greatly alarmed at the gray wound on the day 
following tonsillotomy, the appearance being such as to lead in several 
cases to the diagnosis of diphtheria. This mistake will not be made if 
the possibility of it is borne in mind. It is seldom that any but good 
results follow the operation of tonsillotomy if properly performed. It is 
too often neglected. Where adenoids of the pharynx are also present, the 
symptoms may depend more upon them than upon the enlarged tonsils, 
and little benefit is seen until the adenoid growths also are removed. 
Both may be operated upon at a single sitting, or at two sittings if pre- 
ferred. 

It is not usually necessary to remove the tonsil to a point even w T ith the 
faucial pillars, but the more nearly we can come to this the better. The 
amount of shrinkage from cicatrization after operation has been, in my 
experience, generally less than was expected. As a rule, enlargement 
of the tonsil subsequent to an operation is not seen ; but one should be 
careful about promising parents that it will not occur. I have seen it in 
two or three instances to a striking degree, and think it more likely to 
occur if children operated on are very young — i. e., before the third year. 



CHAPTER IV. 

DISEASES OF THE (ESOPHAGUS. 

MALFORMATIONS. 

Congenital anomalies of the oesophagus are much less frequent than 
those of the lower part of the respiratory tract, with which, however, they 
are often associated. 

There may be, (1) Congenital fistula of the neck, due to a want of 
closure between the second and third branchial arches. This gives an 
external opening just above and to the outside of the sterno-clavicular 
articulation, which communicates with the upper part of the oesophagus 
or the lower part of the pharynx. (2) The oesophagus may be absent, 
the pharynx ending in a blind pouch. (3) The oesophagus may be oblit- 
erated in certain portions, being represented only by a fibrous cord. (4) 
There may be stenosis and dilatation or diverticula. (5) There may be a 



ACUTE OESOPHAGITIS. 275 

fistulous communication with the trachea, existing either alone or asso- 
ciated with some of the other deformities mentioned. 

Congenital narrowing of the oesophagus and fistula of the neck are 
amenable to surgical treatment. The cases of complete obstruction in the 
oesophagus are almost of necessity fatal, the patients dying from inanition 
two or three days after birth. 

The symptoms of oesophageal obstruction are regurgitation on attempts 
at swallowing and the impossibility of passing the stomach tube. 

ACUTE OESOPHAGITIS. 

It is quite remarkable, considering the frequency of pathological pro- 
cesses in the pharynx, that these so rarely extend to the oesophagus. 
Thrush, when very extensive in the pharynx, may involve the upper part 
of the oesophagus ; but there it gives rise to new symptoms. Diphtheria 
and pseudo-diphtheria of the pharynx may invade the oesophagus, but 
this is seen only in very rare instances. In about seventy-five autopsies 
which I have seen in cases of diphtheria, the oesophagus was involved in 
but one, and in this case for three or four inches only. Diphtheria of 
the oesophagus produces no symptoms, and can not be diagnosticated dur- 
ing life. 

Catarrhal Oesophagitis is very rarely met with. It may be caused by 
lacerations "due to swallowing a foreign body, which may excite a simple 
catarrhal inflammation, or, if the foreign body is sharp and angular, 
lacerations may be produced which result in ulcerations of variable depth. 
The chief symptoms of catarrhal oesophagitis are soreness and pain on 
swallowing. These lacerations, when slight, are healed in a few days, and 
are rarely followed by any after-effects. 

Corrosive Oesophagitis. — This is altogether the most frequent form, 
and the only one which is of clinical importance. The usual causes are 
the same as of corrosive gastritis, viz., the swallowing of caustic alkalies or 
strong acids. It is often in tile oesophagus that the most extensive injury 
is done. The effects are superficial or deep, according to the amount 
of the irritant swallowed and its degree of concentration. There may 
be simply a destruction of the epithelial layer, which is followed by no 
serious consequences, or the mucous membrane may be destroyed and the 
submucous coat invaded ; rarely, however, does the injury extend to the 
muscular layer. If the patient survives the dangers incident to the 
irritant poisoning and the acute inflammation which follows, healing by 
granulation and cicatrization takes place, the contraction of the cicatrix 
gradually narrowing the lumen of the oesophagus until stricture is pro- 
duced. 

The early S}-mptoms of corrosive oesophagitis are mingled with those 
of inflammation of the mouth, pharynx, and stomach. There is a burn- 
ing pain in the parts, great thirst, spasm of the oesophagus on attempts at 



276 DISEASES OF THE DIGESTIVE SYSTEM. 

swallowing, so that deglutition may be almost impossible. There follows 
a period of acute inflammation of several days' duration, in which the 
chief local symptoms are dysphagia and pain, and in which the prin- 
cipal danger is that of suffocation from oedema of the glottis. After this 
period has passed, the patient may be comparatively well until the symp- 
toms of stricture begin, usually in from three to six months after the 
injury. 

The indications for treatment in the early stage, are to neutralize the 
caustic in order to prevent if possible its deep action, and in all cases to 
give oils, demulcent drinks, and ice for the local effect, and morphine for 
the pain. 

The treatment of oesophageal stricture is purely surgical, and for this 
the reader is referred to surgical text-books. 

KETRO-CESOPHAGEAL ABSCESS. 

Eetro-oesophageal abscess may result from the breaking down of 
tubercular lymph nodes in the posterior mediastinum, and may give rise 
to symptoms like those which result from an abscess due to Pott's disease, 
from which it can not be diagnosticated. Retro-oesophageal abscess or 
peri- oesophagitis may occur in children after measles, scarlet fever, influ- 
enza, or with syphilis. Here its pathology is the same as retro-pharyngeal 
abscess, differing only in location. Retro-oesophageal adenitis, or enlarge- 
ment of the lymph nodes in the posterior wall of the oesophagus, not 
going on to suppuration, is a rare condition. I have recently met with a 
case in which a tumour nearly an inch in diameter was formed at the 
upper part of the oesophagus, and which caused pressure symptoms, neces- 
sitating tracheotomy. The growth was at first believed to be of a malig- 
nant character, but it completely disappeared after four or five months of 
general treatment, including a summer in the country. 

Perforation of the oesophagus, and a food-fistula connecting the oeso- 
phagus and the trachea, may result from ulceration caused by a tracheal 
canula or by a foreign body. This may be accompanied by abscess. 

The most common variety of retro-oesophageal abscess is that due to 
Pott's disease of the lower cervical or upper dorsal region. The symptoms 
are obscure, and an exact diagnosis is not often made during life. Death 
may occur quite suddenly where the previous symptoms have been so 
slight as to be easily overlooked. The following is a fair example of such 
a case : 

. A little girl two years old, of tubercular family, was admitted to the 
Babies' Hospital in December, 1892, with spinal caries of the upper 
dorsal region. The symptoms were of two months' duration, and already 
there was a spinal deformity consisting of a small knuckle. The patient 
was kept in bed and a plaster-of-Paris jacket applied. A slight febrile 
action of irregular type was present. About a month after admission 



RETRO-CESOPHAGEAL ABSCESS. 277 

dyspnoea was first observed ; this was at times quite intense, and again 
almost absent. It was always on inspiration, expiration being easy. No 
explanation for this was found in the lungs. There was no difficulty in 
swallowing, and very little cough. After these symptoms had lasted for 
about a week, the child while eating was suddenly seized with violent 
dyspnoea, and in a few moments became completely asphyxiated. Trache- 
otomy was immediately done, and by means of artificial respiration the 
patient was restored to comparative comfort. About two hours later a 
second attack occurred, and the patient died in an hour. At the autopsy 
there was found an abscess a little larger than a hen's egg, containing 
about two ounces of curdy pus, overlying the bodies of the first three 
dorsal vertebra and communicating with them. These vertebras were 
carious. The right pneumogastric nerve, an inch and a half above the 
bifurcation of the trachea, was compressed between the abscess and a 
large tubercular lymph node, with the capsule of which it was blended. 
In the lungs were a few small tubercular deposits and the usual conditions 
found in death by asphyxia. The dyspnoea seems to have been of nervous 
and not of mechanical origin, and caused by irritation of the pneumogas- 
tric. The fatal issue was apparently from an increase of the pressure 
upon the nerve. 

A case almost identical with this has been reported by Chapin, and 
others quite similar by Eipley, Richards, and Jarisch. In none of these 
was difficulty in swallowing present, probably because the oesophagus was 
compressed only upon one side. In all there were symptoms of irritation 
of the pneumogastric, or the recurrent laryngeal branch — stridulous breath- 
ing, inspiratory dyspnoea, and spasmodic cough, with or without slight 
hoarseness. In one case only was there aphonia. After such symptoms as 
these have existed for a few days or weeks there usually comes a sudden 
attack of asphyxia. The first attack may be fatal, or there may be several 
of a milder character before the fatal one. In two cases this followed 
a full meal, probably from the increase of pressure due to distention of 
the stomach. In two cases tracheotomy was done, but gave temporary 
relief only. 

The diagnosis of this condition is very difficult, and a positive diag- 
nosis almost impossible. It may be suspected in cases of Pott's disease of 
the lower cervical or upper dorsal regions, when there is spasmodic inspi- 
ratory dyspnoea, especially if accompanied by irritative cough. It should, 
however, be remembered that precisely similar symptoms may depend 
upon the irritation of a tubercular node, and that the sudden asphyxia is 
exactly like that caused by the ulceration of such a node into the trachea 
or a large bronchus. The latter, however, may occur without the pres- 
ence of Pott's disease. If the abscess is higher up, there may be a lateral 
swelling on either side of the neck, just above the clavicle. In most of 
the cases there are no external signs of disease. Such abscesses are too 



278 DISEASES OF THE DIGESTIVE SYSTEM. 

low to be reached by digital examination of the pharynx. The attack 
of asphyxia may also be confounded with that due to the presence of a 
foreign body in the larynx. 

The prognosis in cases of retro- oesophageal abscess is exceedingly bad. 
Death usually results from pressure upon the pneumogastric, as in the 
cases reported. The abscess may rupture into the oesophagus and recov- 
ery follow. This termination is very rare, but such a case has been re- 
ported by Knight. A fatal one is reported by Loschner and Lambl. The 
abscess may burrow along the oesophagus into the abdominal cavity and 
excite peritonitis ; finally, it may open externally. 

But little is to be said under the head of Treatment. The symptoms 
are rarely definite enough to justify a radical surgical operation. Trache- 
otomy gives but temporary relief to the asphyxia. This operation should 
be performed, however, in every case, because of the impossibility of 
making an exact diagnosis of retro-oesophageal abscess from other condi- 
tions in which the operation might be curative. 



CHAPTER V. 
DISEASES OF THE STOMACH. 

It is difficult, wholly to separate diseases of the stomach from those of 
the intestines. Although in older children they are often quite distinct, 
in infancy they are more frequently associated ; but at one time the gastric 
symptoms may be prominent, and at another the intestinal symptoms. 
Functional disorders particularly, are likely to involve the whole tract. 
Serious organic lesions are more frequently limited in their extent either 
to the stomach or to the intestine. The former are rare, while the latter 
are very common. The diseases in which the stomach is alone or chiefly 
involved will be considered by themselves. Those in which both the 
stomach and intestine are involved are classed with the intestinal diseases, 
as the intestinal symptoms usually predominate. 

DIGESTION IN INFANCY. 

The first step in the process of digestion in the newly-born infant is 
sucking. During this act the nipple is grasped between the lower lip and 
tongue below, and the upper lip and jaw above. The back of the mouth 
is closed by the fall of the palate. A strong downward movement of the 
lower jaw rarefies the air in the mouth, and produces the suction force 
which causes the milk to flow. Sucking can be carried on only when the 
nose is free for respiration and the palate and upper jaw intact. Children 
with deformities of the mouth, like cleft palate and harelip, suck only 



PLATE VII 






Different Tekiods < 



N 



DIGESTION IN INFANCY. 



279 



with the greatest difficulty, and complete nasal obstruction prevents 
nursing. 

The Saliva. — This is present at birth only in very small quantity, and 
the part which it plays in digestion in early infancy is an insignifi- 
cant one. During the third and fourth months it increases markedly in 
amount, and at this time it possesses quite actively the power of trans- 
forming starch into sugar. This property is present only to a very slight 
degree during the first eight or ten weeks. With the advent of the teeth 
there is a further increase in the amount of saliva secreted, indicatiug a 
change in the digestion of the infant. 

The Stomach. — The position of the stomach in the foetus is nearly 
vertical. In the newly-born child it lies obliquely in the abdomen, and 
at the end of infancy has almost reached the transverse position. The 
stomach at birth is nearly cylindrical, but the fundus increases quite 
rapidly during the first year, although it does not reach its full develop- 
ment until quite late in childhood. In Plate VII are shown the actual 
size and shape of the stomach at the various periods of infancy. In the 
following table are given the results of post-mortem measurements of the 
stomach, which I have personally made in ninety-one infants under four- 
teen months of age : 

The Capacity of the Stomach. 



Age. 



Birth. . 
2 weeks 
4 " 
6 " 
8 " 
10 " 



Number 


Average 


of cases. 


capacity. 


5 


l-20oz. 


7 


1-50 " 


4 


2-00 " 


11 


2-27 " 


4 


3-37 " 


2 


4-25 " 



Age. 



12 weeks 

14 to 18 weeks 
5 to 6 months 
7 to 8 
10 to 11 « 
12 to 14 " 



Number 
of cases. 



12 

14 

9 

7 

10 



Average 
capacity. 



•50 oz. 
•00 " 
•75 " 
•88 " 
•14 " 
•90 " 



In brief, the average capacity was, at birth, one and one fifth ounce ; 
at three months, four and a half ounces; at six months, six ounces; at 
twelve months, nine ounces. 

Gastric digestion. — The part taken by the stomach in digestion is 
smaller than was formerly supposed, and not so important in infants as in 
adults. The food leaves the stomach so rapidly that a large part of the 
casein must pass into the intestine before it is converted into pq>{<>n< i s. 
The opinion has been steadily gaining ground that the function of the 
stomach is largely that of a reservoir, into which the milk is received and 
from which it is allowed to pass gradually into the intestine; and that the 
gastric process is only a preliminary and partial one, even in the digestion 
of proteids, this being completed in the intestine. 

The only part of the food acted on in the stomach is the proteids, 
which are transformed successively into acid-albumen, albumoses, and 
peptones. This is accomplished by the agency of the pepsin and the acid 



280 DISEASES OF THE DIGESTIVE SYSTEM. 

of the gastric juice — generally hydrochloric acid, although lactic acid may 
take its place. Pepsin is found in the stomach at birth, and even in 
the embryo as early as the fourth month (Kriiger). The reaction of the 
stomach in fasting is acid, and at this time usually free hydrochloric acid 
can be demonstrated. Soon after a meal of human milk it is alkaline or 
neutral ; after one of cow's milk it is acid or neutral. In fifteen minutes 
after feeding the reaction is always acid (Leo). Free hydrochloric acid 
can not usually be demonstrated until about an hour after feeding, then 
only in small quantities, and in very many cases not at all. Some good 
observers go so far as to say that in health free acid is never found during 
digestion. The reason for this apparently is, that the acid combines with 
the casein of the milk, that of cow's milk in particular having a very 
great power of combining with hydrochloric acid. 

Lactic acid is feebler in its digestive power than hydrochloric acid. 
It is more abundant early in infancy than later, and its source is the milk 
sugar. It is rarely found as free acid ; never in health, according to many 
observers. 

The coagulation of milk in the stomach is accomplished through the 
agency of the rennet ferment (the lab-ferment of Hammarsten). This is 
independent of both the pepsin and the acid of the stomach. It acts in 
acid, alkaline, and neutral media. Coagulation is the first change in the 
milk in the stomach. Human milk coagulates in loose flocculi and quite 
imperfectly, more firmly if the stomach is very acid. Cow's milk, unless 
diluted, coagulates in firm, compact masses. Under the influence of pepsin 
and hydrochloric acid, solution of this coagulum now begins ; but this is 
only partly accomplished in the stomach. It goes forward much more 
rapidly in the case of human milk, because the amount of casein is less 
and because of the smaller curds. The milk begins to leave the stomach 
very soon after the meal, and even during the first half hour a consider- 
able part passes into the intestine. At the end of an hour the stomach 
in a young infant is often empty. In the case of cow's milk, not only 
are the coagula firmer, but the amount of casein present is much larger, 
and hence the milk is detained in the stomach a longer time; even 
then a considerable portion of it must pass but little changed into the 
intestine. 

The duration of gastric digestion varies with the age of the infant 
and with the food. During the first month the stomach of healthy 
nursing infants is usually found empty in an hour and a half after feed- 
ing; often after one hour. In those taking cow's milk the average is 
at least half an hour longer. In infants from two to eight months old 
the average is two hours for those receiving breast milk, and two and a 
half to three hours for those fed upon cow's milk. This is influenced by 
the size of the meal taken. This period is very much longer in all cases 
of disordered digestion. 



DIGESTION IN INFANCY. 281 

The bacteria of the stomach are very few as compared with the intes- 
tine, and no varieties are constantly present (Booker). 

The Intestines. — The length of the small intestine at birth is about 
nine feet ; that of the large intestine about eighteen inches. The great 
length of the sigmoid flexure is the most striking peculiarity, this being 
nearly one half the length of the large intestine. (See page 64). 

Intestinal digestion. — All the important elements of food — proteids, 
carbohydrates, and fats — are acted upon by the pancreatic juice. The 
proteids are converted into peptones by the trypsin, which is active only 
in an alkaline medium. How much of the proteids of the milk is left 
for intestinal digestion, depends upon how well the stomach has done its 
part. In every case something is left ; in most cases a large part of the 
proteids passes but little changed into the intestine. The diastatic fer- 
ment of the pancreas has the power of converting starch into sugar. 
This action is feeble during the first six months, and, according to 
Koronin and Zweifel, it is entirely absent in early infancy. Fats are 
emulsified by a third ferment in the pancreatic juice, in connection with 
bile, which probably furnishes the needed alkali. Some of the fats are 
also saponified. The pancreatic juice actively emulsifies fat, even at 
birth. 

The very large size of the liver in the newly-born indicates how im- 
portant are its functions in digestion. The biliary secretion is present as 
early as the third month of foetal life (Zweifel). Bile assists in the diges- 
tion and absorption of fats, as has already been mentioned. In addition 
it is a stimulus to peristalsis, and in this way aids in the absorption of all 
kinds of food. Its antiseptic effect is very doubtful. It has a feeble 
diastatic action upon starch. The greater part of the bile is reabsorbed 
from the intestine. 

Milk sugar is changed into galactose (Biedert), cane sugar into dex- 
trose and levulose, all three being closely allied substances. Through 
what agency these changes are accomplished is not now positively known, 
but it is probably the pancreatic juice. 

The action of the intestinal juice is not perfectly understood ; its chief 
function is thought to be diastatic. It is alkaline in reaction, and prob- 
ably facilitates the action of the trypsin, the diastatic ferment, and the 
absorption of fats. 

Absorption. — From the stomach, absorption of water, salts, sugar, and 
peptones may take place directly into the blood. From the small intestine, 
in addition to the above elements, fat is absorbed especially by the villi. 
Absorption is less active than secretion in the small intestine, except in 
the duodenum. It is accomplished through the agency of the villi and 
the simple follicles of the mucous membrane. It is perhaps partly by 
filtration and endosmosis, but chiefly through the activity of the epithelial 
cells themselves (Hoppe-Seyler, Haidenhain). Absorption from the large 



282 DISEASES OP THE DIGESTIVE SYSTEM. 

intestine is quite imperfect. There are no villi, and hence fat absorption 
is very slight. Sugar, salts, and peptones, however, may be absorbed with 
moderate facility. Since there is little or no digestive activity in the 
large intestine, if this is used as a means of nutrition, the food must be 
given in a condition in which it is ready for absorption. 

Even in healthy nursing infants complete absorption takes place only 
in the milk sugar. From two to five per cent of the proteids and fats 
taken, pass through the intestinal canal. In infants taking cow's milk the 
fat-residue is from one to three per cent greater than in those who are 
breast-fed (Uffelmann). Even when the amount of fat given is consid- 
erably greater than that usually present in cow's milk, it may be almost 
entirely absorbed. In infants taking cow's milk the proteid residue is 
relatively much greater than that of the fat. 

In cases of indigestion the increase in the food-residue in most cases 
is first in the proteids, next in the fat, and least in the sugar. In some 
of the chronic cases the principal increase may be in the fat-residue. 

Intestinal Bacteria. — For the fundamental work upon this subject we 
are indebted to the researches of Escherich. Bacteria are absent from 
the entire gastro-enteric tract at birth. They quickly enter by the mouth, 
and by the end of twenty-four hours they are usually found in all parts of 
the intestinal tract. The meconium-bacteria are derived from the in- 
spired air, and hence vary somewhat with surroundings. As soon as the 
ingestion of milk begins these varieties are displaced, and throughout the 
period in which the infant has this food exclusively, there have been found 
in healthy conditions but two varieties which are constantly present. 
These are the bacterium lactis aerogenes and the bacterium coli commune. 
The first is found most abundantly in the upper part of the small intes- 
tine, diminishing as we descend, in small numbers only in the colon, and 
usually none are in the faeces. It seems to require for its growth the pres- 
ence of milk sugar, hence its absence from that part of the intestine where 
milk sugar is not found. Milk sugar is decomposed by it with the forma- 
tion of lactic acid (acetic, according to Baginsky), carbon dioxide, hy- 
drogen, and methane. This action is not hindered by the bile. The 
b. lactis has no action of importance on either the fat or casein of the 
milk. 

The b. coli commune is found in but small numbers in the upper 
small intestine, becoming more abundant as we descend. In the colon 
and in the faeces it is present in immense numbers, and in the faeces is 
sometimes almost the only variety. The activity of the b. coli commune 
apparently begins where that of the b. lactis ends, viz., in the lower part 
of the small intestine. It does not seem to depend for its growth upon 
any part of the food, but upon the intestinal secretions. A change from 
a milk diet to a mixed diet of meat and farinaceous food, produces a con- 
stant change in the bacteria of the intestine. The b. lactis disappears; 



DIGESTION IN INFANCY. 283 

the b. coli commune, however, continues to be found as the principal form 
of the colon. 

Kegarding the meaning of these bacteria but little is as yet known. 
We do not know whether they are essential to healthy digestion or preju- 
dicial to it. The b. lactis is believed not to be pathogenic. There seems 
to be accumulating evidence in favour of the view that the b. coli com- 
mune, though not ordinarily pathogenic, may under certain conditions 
become so. 

Faeces. — The first discharges after birth are called meconium ; this is 
of a dark brownish-green colour, semi-solid, and usually passed from 
four to six times daily during the first two or three days. On the third 
day the stools begin to change in character, and by the fourth or fifth 
day they have usually assumed the appearance of healthy milk-fasces. Un- 
der many abnormal conditions the stools may continue to have the char- 
acter of meconium for a week or more. The composition of meconium, 
according to Forster, is intestinal mucus, bile, the vernix caseosa, epithe- 
lial cells from the epidermis, hairs, fat-globules, and cholesterin crystals. 
For its formation there are necessary the secretions of the intestine 
and the liver and the swallowing of a considerable amount of amniotic 
fluid. 

Milh-fcBces. — The normal amount of faeces discharged daily by a 
healthy nursing infant is from two to three ounces. Such stools have the 
colour of the yolk of egg. They are smooth, homogeneous, of a soft, but- 
ter-like consistency, with an acid reaction, and a slightly acid but not 
unpleasant odour. The reaction is due to the presence of fatty acids 
(Biedert) or lactic acid (Uffelmann). The colour depends upon bilirubin. 
The stools of an infant fed upon cow's milk may differ in no respect from 
those described ; they are, however, commonly firmer, paler, and may be 
neutral or even alkaline in reaction, depending upon the decomposition of 
casein. In fact, all these differences depend chiefly upon the presence 
of undigested casein. 

The only gases present are hydrogen and carbon dioxide (Escherich). 
Sulphuretted hydrogen and marsh gas, to which the odour of adult stools 
is largely due, are not present. The following is the chemical composition 
as given by Wegscheider : 

Water ' 85-13 

Solids -i. 0r ^ anic 13 ' 71 ,[ 14-87 

( Inorganic 1 • 16 ) 

100-00 

The proteids of breast milk are almost entirely absorbed. According 
to Uffelmann, they form but 1*5 per cent of the dry residue of the faeces. 
The stools of infants fed upon cow's milk are usually larger, and invari- 
ably contain casein. If the casein in the milk as fed is excessive, it may 
be present in the faeces in large amount, the stools then being of a pale 



284 DISEASES OP THE DIGESTIVE SYSTEM. 

yellow or white colour, quite dry, often formed, and with an odour some- 
times cheesy, at other times foul. 

Fat is always present, and forms, according to Wegscheider and Uffel- 
mann, from 9 to 25 per cent of the dry residue of milk faeces. According 
to Tschernoff and some other recent observers, the proportion is as high 
as 28 to 35 per cent. It is present as neutral fat, fatty acids, and soaps. 
Sugar is not found, but its derivative, lactic acid, may be present in a 
small amount. Inorganic salts form about 8 per cent of the dry residue. 
They are chiefly the salts of lime. Of the biliary elements there are hydro- 
bilirubin, unchanged bilirubin, and cholesterin in considerable amount. 
The presence of biliary acids is doubtful. Mucus is always present in con- 
siderable quantity ; also columnar intestinal epithelium. Leucin, tyrosin, 
and other products of albuminous decomposition — phenol and skatol — 
are absent ; indol is rarely found (Uffelmann). 

Microscopically there are seen epithelial cells, chiefly of the columnar 
variety, a few round cells, mucous corpuscles, fat-globules and crystals of 
fatty acids, cholesterin, mucin, protein substance, crystalline inorganic 
salts, sometimes bilirubin in crystals, yeast fungi, and bacteria in immense 
numbers, chiefly the b. coli commune. 

If the infant is taking a food containing starch, this will appear to a 
greater or less extent in the stools, a larger amount in the case of very 
young infants. Starch is recognised by the blue reaction with iodine, 
or the violet reaction if the starch has been converted into dextrine, as is 
often the case. Starch granules may be seen under the microscope. 

The number of stools during the first two weeks is from three to six 
daily. After the first month two stools a day are the average; many 
infants have three, many others but one. 

As soon as an infant is put upon a mixed diet, the peculiar characters 
of the stools cease, and they come to resemble more closely those of the 
adult, though remaining softer throughout infancy. They become darker 
in colour and assume the adult odour, while retaining their acid reaction. 
The bacteria, while still in great numbers, are no longer of the single 
variety met with almost exclusively in milk-fa3ces. 

MALFORMATIONS AND MALPOSITIONS OF THE STOMACH. 
These are much less frequent than those of other parts of the alimen- 
tary tract. There may be atresia or stenosis at either orifice, usually the 
pyloric ; still more rarely a constriction has been found near the middle 
of the organ, dividing it into compartments. The symptoms of atresia at 
either orifice are persistent vomiting, and death in a few days from inani- 
tion. The stomach is sometimes in the thoracic cavity in cases of dia- 
phragmatic hernia. It may be found in a vertical (foetal) position, 
variously adherent to the colon and small intestine. 



VOMITING. 285 

VOMITING. 

Vomiting is exceedingly frequent in infants and young children, and 
although seen in many forms of disease, it is the one particular symptom 
to attract attention to the stomach. The physician must have in mind 
both its common and its uncommon causes. Vomiting takes place with 
great facility in young infants even from slight causes, owing to the posi- 
tion and shape of the stomach. 

1. Vomiting from overfilling of the stomach. — This is often seen in 
nursing infants, and there may be no other symptom of disease. It is 
characterized by the fact that it comes within a few minutes after nurs- 
ing, that it is easy and without effort, and that the food is but little 
changed. It may be excited by moving the child or making undue pres- 
sure upon the stomach. It often comes with eructations of gas or air 
which has been swallowed. Vomiting from overdistention may be re- 
garded as a safety-valve, and requires no treatment except to diminish 
the quantity of food. 

2. Vomiting is almost invariably present in cases of acute gastric indi- 
gestion, whether there is inflammation of the stomach or not. It does 
not usually come immediately after feeding, and it may be delayed for 
several hours. It is often preceded by fever and by marked prostration, 
which in young infants may approach collapse. It may cease when the 
contents of the stomach have been evacuated, but often mucus, serum, 
and, in severe cases, bile, may be vomited for some time afterward. In 
these cases vomiting is due to the irritation of undigested food, and to 
the exaggerated reflex irritability of the stomach from congestion of the 
mucous membrane. 

3. In acute intestinal obstruction vomiting is rarely absent, and in 
most cases it is persistent. In the newly-born, persistent vomiting is 
almost invariably dependent upon congenital obstruction of the intestine, 
which is most frequently in the duodenum. In malformations of the 
colon and rectum it is less constant and appears later. In intussuscep- 
tion, vomiting is forcible, immediately excited by the taking of food, and 
is at first bilious, but later may become faecal. The vomiting in intes- 
tinal obstruction is associated with general symptoms of marked prostra- 
tion, and usually with obstipation. 

4. Vomiting is a frequent and almost a constant symptom of general 
peritonitis. It is then associated with abdominal distention, tenderness, 
and fever. 

5. In certain nervous diseases, especially tumour of the brain and acute 
meningitis whether simple or tubercular, vomiting is very common. It 
may be the earliest, and for some time the only marked symptom. As in 
the vomiting from intestinal obstruction, this is likely to be sudden, forci- 
ble, or projectile. It may occur after taking food, or it may have no rela- 



286 DISEASES OF THE DIGESTIVE SYSTEM. 

tion to meals. The vomited matters are not characteristic, and the tongue 
may be clean. Headache, dulness, slight fever, constipation, and irregular 
pulse and respiration are usually present sooner or later, and serve to 
make the diagnosis complete. 

6. In infants, vomiting is one of the most frequent symptoms to 
mark the onset of acute infectious diseases. It is not quite so common 
in older children. It is most frequent at the onset of scarlet fever, 
pneumonia, and malaria. In these cases vomiting may be due simply 
to the arrest of digestion, or to the effects of the poison upon the nerve 
centres. 

7. An accumulation in the blood of various toxic materials may pro- 
voke vomiting ; the most frequent example is uraemia. In cyclic vomiting 
it is quite probable that the cause is the accumulation of some toxic agent 
in the blood. The absorption of ptomaines and other poisons taken in 
with milk or other food, or developed in the gastro-enteric tract, may ex- 
cite vomiting. In some of these conditions it is possible that the vomiting 
may be eliminative — an effort on the part of Nature to get rid of the 
toxic materials. The cases dependent upon renal disease are discovered 
by frequent and careful examination of the urine. The other forms are 
often exceedingly obscure, and recognised only by the exclusion of all 
other frequent and infrequent causes of vomiting. 

8. Vomiting may be reflex from irritation in the pharynx. This is 
frequent in young infants, who may induce vomiting by stuffing the 
fingers into the mouth. In certain cases the irritation from worms in the 
intestinal tract may cause vomiting, and it is possible that even dentition 
may produce it. 

9. Habit is a frequent cause in cases of chronic vomiting. I have 
seen a child who had the power of vomiting at will anything in the nature 
of food which he did not like, yet whose stomach at the same time would 
bear large doses of quinine, to which he had no aversion, without the 
slightest disturbance. In young infants a habit of regurgitating the 
food may be acquired, so that this takes place more or less during the 
process of digestion after every meal. This is sometimes preceded by a 
movement of the mouth and fauces resembling swallowing, until finally 
the milk appears in the mouth. Habit is a potent cause in continuing 
vomiting where it has occurred frequently. In children who have this 
habit the most trivial cause will provoke it. It may be present without 
any other sign of gastric disease, and appears simply to depend upon 
exaggerated reflex irritability of the organ. These are exceedingly 
troublesome cases to control. Sometimes small quantities of food are 
better borne, and sometimes larger meals are retained when small ones 
are vomited. In some of these children gavage is the only means by 
which the vomiting can be controlled. 

10. Chronic vomiting may depend upon habit, as just described, or 



CYCLIC VOMITING. 287 

upon chronic indigestion, or it may be associated with chronic pulmonary 
disease ; vomiting here being excited by the attacks of cough, at first only 
when the paroxysms are severe, and later even when they are slight. In 
chronic indigestion the vomited matters always are characteristic, they 
have a distinct relation to meals, and they are accompanied by other 
symptoms of deranged nutrition. 

The diagnosis of a case in which vomiting is the chief symptom 
may be difficult. The first important distinction to be made is between 
cases in which the vomiting is of gastric origin, and those in which 
it depends upon other conditions, like intestinal obstruction, cerebral 
disease, toxic conditions, etc. It is only by a careful consideration 
of the other symptoms associated that an accurate diagnosis can be 
reached. 

The treatment of vomiting is the treatment of the cause upon which 
it depends. 

CYCLIC VOMITING. 

This condition is one which has received but little attention. It is 
classed by some as a gastric neurosis. While at the present time we are 
not in a position to give it a definite pathology, it seems to be associated 
with a general derangement of nutrition which is in some way connected 
with formation and excretion of uric acid. It is not certain that all 
these cases' have the same origin. 

The disease is characterized by periodical attacks of vomiting, recur- 
ring at intervals of weeks or months without any adequate exciting cause. 
The vomiting is severe and uncontrollable, and usually lasts from twelve 
hours to three days. It is attended with symptoms of general prostration 
which may be alarming. The children who are subjects of it may show 
in the interval nearly all the signs of perfect health. The clinical picture 
presented by these cases is unique, and is well illustrated by the history 
of the following case, which is the most characteristic one that has come 
under my observation : 

The patient was a well-nourished boy of six years when he first came 
under treatment. He belonged to a neurotic family, and the attacks dated 
back to infancy. From this time they had recurred usually at intervals of 
a few months ; occasionally five or six months would pass without one. 
The symptoms in all the attacks were similar in kind, differing only in 
degree. I observed three of them. They were preceded by a prodromal 
period lasting from twelve to twenty-four hours, marked by languor, d ill- 
ness, dark rings under the eyes, loss of appetite, and a general sense of 
discomfort in the epigastrium. . At this time the temperature was gener- 
ally but not always elevated, sometimes to 103° F. The vomiting then 
began suddenly. It was attended with great retching and distress; it 
was forcible, and often repeated every half hour or hour for two days. On 



288 DISEASES OF THE DIGESTIVE SYSTEM. 

one occasion it occurred seventeen times in a single night. Vomiting was 
immediately excited by the taking of any food or drink, but it occurred 
when nothing was taken. The vomited matters consisted of frothy mucus 
and serum, frequently streaked with blood, apparently from the violence 
of the emesis. The reaction was very strongly acid; sometimes there was 
bilious vomiting. The temperature usually fell to about 100° F. when the 
vomiting began, and continued at or below this point throughout the 
attack. By the end of the second day the exhaustion was very marked — 
so severe, in fact, as apparently to threaten life. The child lay in a semi- 
stupor, with eyes half open, lips and tongue dry, rousing at times to beg 
for water. The pulse was rapid and weak, and sometimes slightly irregu- 
lar. There was no distention of the abdomen ; it was usually flattened. 
By the third day the vomiting became less frequent and then ceased 
entirely. Convalescence was rapid, and by the end of the week the 
boy was as well as usual. After these attacks he was frequently better 
than for some time previously. Several other cases have come under 
my observation, all closely resembling this one, but, with a single excep- 
tion, the symptoms were not so severe. In that child the attacks lasted 
regularly five days. 

A very similar case to the one whose history is given above, has been 
reported by Snow * (Buffalo). Gee f has published a series of nine cases 
of cyclic vomiting, two of which were of the type described, but much 
less severe. 

Judging from these limited observations, cases may be seen at any 
period of childhood, and more frequently 1 in girls than in boys. They are 
often seen in neurotic or gouty families. The general health and nutri- 
tion of the patients may appear excellent. The attacks are rarely trace- 
able to the taking of indigestible food, and they have little in common 
with an ordinary severe attack of acute indigestion. Exhaustion or fatigue 
may bring on an attack, and one has been excited by some minor illness 
such as tonsillitis. The prodromal symptoms are lassitude, frequently 
headache, a sense of gastric discomfort, and very often fever, which, how- 
ever, does not continue through the illness. In many of the cases, for 
some days before the attack, the stools are noticed to be almost white. 
Constipation is not marked, and is often absent. Severe epigastric pain is 
rare. The attacks seem to be self -limited, and they are but little affected 
by treatment. 

Cyclic vomiting is certainly a nervous and not a gastric condition. It 
has many points of resemblance to an attack of migraine. The following 
observations made by Dr. C. A. Herter upon the urine of the case whose 
history I have given, strengthens this hypothesis, since the result is almost 

* Archives of Paediatrics, 1893. 

f St. Bartholomew's Hospital Reports, 1882. 



CYCLIC VOMITING. 



289 



identical with what is found in migraine. All the following observations 
were made upon the twentj-f our-hours' urine : 



Time taken. 



Before the attack (normal) . 

First day , 

Second day 

Third day (convalescent). . . 
Several weeks after (normal) 



Urea, 


Uric acid, 


Eatio of uric 


grammes. 


grammes. 


acid to urea. 


13-606 


0-251 


1 to 54 


17 249 


0-110 


1 to 157 


12-023 


0-0912 


1 to 132 


11-713 


0-234 


1 to 50 


15-040 


0-283 


1 to 53 



Observations made upon the urine in a second attack, three months 
later, gave results which were practically identical with the above. A 
second case of a somewhat similar type, but less severe, showed a ratio of 
uric acid to urea 1 to 83 during the vomiting, while in the same individual 
in health it was 1 to 42. Further observations are necessary before the 
full significance of these changes can be appreciated. The frequency 
with which the attacks are preceded by light gray stools, indicates that 
disturbance of the functions of the liver has a very close connection with 
the symptoms. 

The prostration from the attacks is usually of short duration. The 
paroxysms are apt to recur unless a proper treatment of the case in the 
interval can be carried out. There seems but little tendency to spontane- 
ous recovery. In most of the cases reported they have extended over a 
period of several years. 

Diagnosis. — Organic disease of the brain and kidneys must first be 
excluded, the latter only by careful and repeated examination of the urine. 
The first attack witnessed may strongly suggest the onset of meningitis, 
but the course of the symptoms soon shows that this is not present. Usu- 
ally a history of many previous attacks may be obtained. From acute 
indigestion, cyclic vomiting is differentiated by the fact that attacks are 
not brought on by indigestible food and also by the persistence of the 
vomiting. It is distinguished from gastritis by its severity, the shorter 
duration of its symptoms, and its self-limited course. 

Treatment. — When the premonitory symptoms appear, free purgation 
by calomel offers the best prospect of aborting an attack. If the vomit- 
ing has once begun, nothing seems to have the slightest influence in con- 
trolling it. It is usually increased by the taking of food or drink or by any 
medication by the mouth, and all should be withheld. Ice may be held 
in the mouth to allay thirst. When the vomiting has ceased for several 
hours it is not likely to recur if food be very judiciously administered and 
in small quantities. Broth, whey, kumyss, or small quantities of iced milk 
and limewater in equal proportions may then be given. Acting upon the 
theory that the symptoms were analogous to those of migraine, the treat- 
ment I have adopted in the interval has been purely dietetic, consisting 
24 



290 DISEASES OF THE DIGESTIVE SYSTEM. 

in the exclusion of all sugar and sweets, and in carefully limiting the 
amount of starchy foods. The diet prescribed has consisted of meat, green 
vegetables, milk, sour fruits, and stale bread. This diet has been followed 
in the case reported, with the result that instead of having four or five 
attacks every year there had been at the last report but one attack in three 
years. In addition to careful regulation of the diet the general nutrition 
should be considered, and the patient's life so regulated that extreme 
fatigue and exhaustion should be prevented. 

GASTRALGIA. 

This term is applied to sudden, severe attacks of gastric pain. Gas- 
tralgia occurs as a symptom in most of the severe attacks of acute gastric 
indigestion ; in such cases it is more marked in older children than in 
infancy. The pain of diaphragmatic pleurisy is often referred to the epi- 
gastrium, and may be so severe as to lead one to think that the stomach is 
the seat of disease. In vertebral caries of the dorsal region epigastric 
pain is a very frequent, early symptom. It is also common in children 
who suffer from malaria, at the onset of acute attacks, and it may be severe 
when the febrile symptoms are not well marked. In other cases pain in 
the stomach is of the nature of a true neuralgia, which may be excited by 
exposure to cold, by wetting the feet, by drinking ice-water, and by many 
other causes. Children who are predisposed to it often have attacks of 
considerable severity from comparatively slight causes. 

In mild cases there is an intermittent pain, and usually no other symp- 
toms. In severe cases the pain may be so great as to cause pallor, faint- 
ness, cold perspiration, and very marked prostration. When the origin of 
the pain is in the stomach the epigastrium may be hard and sometimes 
retracted, the stomach appearing to be in a state of spasm. 

Treatment. — During the attacks the patient should be put to bed, and 
counter-irritation used over the stomach, best by means of a turpentine 
stupe or a mustard paste ; sometimes a hot- water bag will suffice. Inter- 
nally there should be given hot water containing brandy or gin and 
five drops of spirits of chloroform; all food should be withheld. Hot 
bottles should be applied to the feet if they are cold. In the interval 
between the attacks the treatment should be directed to the patient's gen- 
eral condition ; especially should the cause be discovered. In cases of 
recurring pain of a neuralgic character the prolonged use of arsenic in the 
form of Fowler's solution, three or four drops three times a day, may 
prove of great benefit. In all cases attention should be directed to the 
diet, as in chronic indigestion. 

ACUTE GASTRIC INDIGESTION. 

This occurs whenever the stomach is unequal to the task imposed upon 
it. It may be either because the task is too great or because the capacity 



ACUTE GASTRIC INDIGESTION. 291 

of the stomach for work is diminished. Under these two heads we may- 
group the principal causes of acute indigestion. 

Under the first head the most important thing is the giving of im- 
proper food. In infants this is most frequently the use of cow's milk 
which contains too much casein because not sufficiently diluted. Other 
common causes are sudden weaning or any other abrupt change in diet, 
the too early use of solid food, and overloading of the stomach. In older 
children the usual causes are the use of indigestible articles, such as unripe 
fruits, pastry, etc., overloading the stomach, and swallowing food without 
sufficiently masticating it. Conditions which may diminish for a time the 
capacity of the stomach for work are fatigue, depression induced by atmos- 
pheric heat, chilling of the surface, especially the extremities, dentition, 
and the nervous impression caused by the onset of any acute disease. The 
effect is seen both on the glandular and muscular apparatus of the stom- 
ach. The secretions are diminished or altered in character, and the motor 
activity of the organ is arrested. 

Symptoms. — One of the first consequences of arrested gastric digestion 
is that the food remains long in the stomach. Instead of being empty in 
two or two and a half hours after feeding, as is normal in infancy, the 
food may remain in the stomach five or six hours, or even longer. The 
irritation from this undigested mass excites vomiting, which usually ceases 
after the stomach has been emptied. The vomiting may be preceded by 
nausea, pain, and constitutional depression which varies with the age and 
susceptibility of the child ; in infants it may be very alarming. 

It seems probable that, as a consequence of arrested gastric digestion, 
the proteids are not converted into peptones, but remain in the form of 
albumoses. These products have been shown by experiments on animals 
to be toxic, producing stupor and circulatory disturbances. They are 
diffusible and are undoubtedly absorbed with great rapidity, and may be 
the cause of nervous symptoms of a striking character. There may be 
dulness, stupor, and sometimes contracted pupils, so as to suggest opium 
narcosis, or there may be restlessness, excitement, and even convulsions. 
There is also marked prostration, weak pulse, and fever. The tempera- 
ture in most cases of acute indigestion is from 100° to 102° F. ; not infre- 
quently it rises to 104° or 105° F. The tongue is coated and the appetite 
entirely lost. In infants these symptoms are usually associated with more 
or less evidence of intestinal disturbance — generally diarrhoea, with undi- 
gested food in the stools. Epigastric distention may be present. Usually 
the vomiting ceases in from six to twelve hours, and after the stomach 
has been thoroughly emptied the temperature falls. Provided rest to the 
organ can be secured, and the exciting cause is one that can be removed, 
the patient may be quite well in two or three days. Relapses are, how- 
ever, easily excited. It is surprising to see in a susceptible patient how 
trivial a cause may excite a relapse. 



292 DISEASES OF THE DIGESTIVE SYSTEM. 

The diagnosis between a simple attack of acute indigestion and one of 
gastritis can not be made at the outset. The former is. much more fre- 
quent, and may be quite as severe, but is of shorter duration. The con- 
tinuance of the severe symptoms, especially pain, thirst, fever, and vomit- 
ing of mucus tinged with blood, justify the inference that inflammatory 
changes exist. The prognosis in these cases is good, except in very young 
or very delicate infants. In such patients an attack of acute indigestion 
is not infrequently fatal. 

Treatment. — The indications are, to empty the stomach as completely 
as possible and then to secure to it absolute rest. If proper treatment is 
employed at the outset, the majority of such attacks can be cut short. 
Nothing is so -efficient in infants as stomach- washing. (See page 60). 
A single washing usually suffices. If for any reason this can not be em- 
ployed, the child may take from its bottle a large amount of lukewarm 
water. The free vomiting which this usually produces may be sufficient 
to cleanse the stomach fairly well, but by no means so easily as stomach- 
washing. Persistent vomiting is sometimes arrested by giving small quan- 
tities of quite hot water. 

The subsequent treatment is chiefly dietetic. Nothing whatever is to 
be given for three or four hours, and then albumen water * or ice-cold 
whey (page 152), frequently, and in small quantities — e. g., half an ounce 
to one ounce every hour. After twenty -four hours barley water, raw beef 
juice or broth may be tried, but no milk for at least three days. When 
begun, it should be peptonized and diluted with three or four parts of 
water. In a nursing child, the breast should be withheld altogether for 
twenty-four hours, and then nursing allowed for two minutes every three 
hours, the time of nursing being gradually increased to three, five, and ten 
minutes as improvement occurs. The great mistake made in these cases 
is to begin food too early and to give too much, especially of cow's milk. 

Drugs are relatively of little value. If the measures mentioned have 
been used promptly they will not often be required. In many cases inju- 
dicious medication aggravates the symptoms and prolongs the attack. 
Unless the bowels have acted freely, calomel (gr. y 1 ^ every hour) may be 
given until this effect is obtained. Where there is continuous vomiting 
of very acid mucus and serum, alkalies are indicated — limewater, chalk 
mixture, or the subcarbonate of bismuth. It is important to keep the 
child as quiet as possible. Local applications to the epigastrium are very 
often useful. Either dry heat may be applied by means of a hot-water 
bag or hot flannels, or more active counter-irritation by mustard. In 
older children the stomach is to be emptied by an emetic, such as ipecac, 
accompanied by large draughts of warm water. After this it should be 

* Albumen-water : The white of one fresh egg, one half pint cold water, previously 
boiled, a little salt, one teaspoon Cul of brandy ; shake thoroughly, and feed cold. 



ACUTE GASTRITIS. 293 

kept entirely at rest for half a day, only carbonated waters or barley water 
being allowed in small quantities to allay thirst. Later, broth or beef 
juice may be given, then milk diluted with two parts of limewater. The 
patient should be kept upon a very low diet for four or five days. 

ACUTE GASTRITIS. 

In comparison with the frequency of inflammatory diseases of the 
intestine, those of the stomach are rare, particularly so in infancy. Gas- 
tritis seldom exists alone, but is usually associated with enteritis or colitis. 

Etiology. — The causes of gastritis are, in the main, those of acute 
gastric indigestion — improper food or feeding. Besides, it may be caused 
by the introduction of irritants, which may either be accidentally swal- 
lowed or given as drugs. The mucous membrane of the stomach has 
much more resistance to infection than has that of the intestines ; but in 
certain forms of inflammation, especially the membranous, infection is 
clearly the cause. 

Lesions. — The mucous membrane of the stomach may be the seat of 
acute catarrhal, follicular, or membranous inflammation, all forms except 
the catarrhal being very rare. There is also seen a mixed form, from its 
cause usually designated as " corrosive " gastritis. 

Catarrhal gastritis. — This is characterized by hyperemia of the mu- 
cous membrane, exudation of cells into the mucosa, a great increase 
in the secretion of the mucous glands, and changes in the epithelium. 
About the only change which can be recognised by the naked eye is 
congestion and swelling of the mucous membrane. These are usually 
more marked toward the pyloric end and along the greater curvature. 
There may be small extravasations of blood into the mucosa. The stom- 
ach contains undigested food and mucus, which may be thick and tena- 
cious, adhering very closely to the mucous membrane. The mucus may 
be stained brown from the capillary haemorrhages. The stomach may be 
either distended or contracted. Under the microscope the changes are 
seen to be almost entirely in the mucosa. In places there is loss of the 
superficial epithelium, in others only degenerative changes in it are seen. 
The mucosa is infiltrated with round cells, this process being rarely diffuse, 
but generally occurring in patches. The blood-vessels are distended and 
many small extravasations are seen. Sometimes there is a moderate infil- 
tration of the submucosa. Acute catarrhal gastritis alone is rarely severe 
enough to cause death. It is usually seen in cases which prove fatal 
from other causes, particularly diseases of the intestine. 

Gastric softening (gastromalacia) is a condition dependent upon post- 
mortem changes — probably self-digestion of the stomach. It is found 
both where gastric symptoms have been present and where they were ab- 
sent. It is situated nearly always in the posterior wall, and usually covers 
a considerable area, about one third or one fourth of this wall. It is 



294 DISEASES OF THE DIGESTIVE SYSTEM. 

recognised by the gelatinous, translucent appearance of the walls of the 
stomach, which are so softened that the finger may be pushed through 
them without force, sometimes so that the stomach ruj)tures while it is 
being removed. This condition is rarely seen when the stomach is empty. 
It can scarcely be mistaken for a pathological condition, if its occurrence 
is borne in mind. 

Follicular gastritis. — This is usually seen in connection with catarrhal 
inflammation, but it may form the most important feature of the lesion. 
The cases are quite rare. I have met with one marked example in an 
infant three weeks old. The others I have seen were associated with ileo- 
colitis. The characteristic feature is inflammation of the solitary lymph 
nodules of the stomach, which, like those in the colon, undergo swelling, 
softening, and ulceration. The lesion can not be recognised by the naked 
eye, unless ulcers are present. These appear rather thinly scattered over 
the mucous membrane of the stomach, about a line in diameter. They 
are never closely set as in the intestine. Large follicular ulcers I have 
never seen. Under the microscope the ulcers are seen to be in all respects 
similar to those found in the colon, except that they are smaller and more 
superficially situated, generally being entirely in the mucosa. 

Membranous gastritis. — This is even more rare than the varieties pre- 
viously mentioned. I have met with it but four times. One case was 
associated with a membranous colitis ; a second case with pseudo-diph- 
theria of the fauces and larynx in an infant but six weeks old. The 
oesophagus was not involved in' this case; and indeed it often escapes. 
No Loeffler bacilli could be found either in cover-slip preparations or by 
culture. Both these cases have been very fully reported by Dr. Martha 
Wollstein.* To the naked eye the membrane appears as of a grayish- 
green colour ; it is adherent, but can be detached, in quite large patches. 
Only a portion of the stomach was covered in any of the cases ; in two 
the principal disease was about the pylorus ; in another along the greater 
curvature. In Fenwick's case the entire surface of the stomach was 
lined with membrane. The microscopical appearances resemble those of 
membranous colitis. There is a pseudo-membrane composed of fibrin, 
granular matter, epithelial cells, and bacteria. The mucosa shows a mod- 
erately dense infiltration with round cells, and in places superficial ulcera- 
tion. There is also infiltration of the submucosa, and in some places even 
the muscular coat is involved. 

Membranous gastritis occurring in patients dying of diphtheria has 
been described by Smirnow, Andral, Killiet and Barthez, Calm, Fenwick, 
and others, but I have not been able to find any case in which the diag- 
nosis of true diphtheria of the stomach was confirmed by cultures. 

* Archives of P.-rdiatrics, July, 1892. Here will be found an excellent summary of 
the literature of membranous gastritis. 



ACUTE GASTRITIS. 295 

Corrosive gastritis {toxic gastritis). — This form, of inflammation is 
excited by various irritating and caustic substances, which, are usually 
taken by accident, sometimes for the purpose of producing emesis. The 
most frequent substances are carbolic acid, caustic alkalies, mineral acids, 
arsenic, salts of copper, zinc, or antimony, croton oil, and corrosive sub- 
limate. 

The lesions in the stomach depend upon the amount of the substance 
swallowed, the degree of concentration, and whether the stomach was 
full or empty at the time. Strong caustics, whether acids or alkalies, 
usually act more deeply and extensively in the pharynx and oesophagus, 
for, owing to the spasmodic contraction of the muscles of these parts, 
often but a small amount of the substance reaches the stomach. Concen- 
trated irritant poisons produce in the stomach irregular ulcers, especially 
along the greater curvature, which may be so deep as to cause perforation, 
or they may affect the mucous membrane only. In severe cases death 
takes place early, often in a few hours. Dark, ragged ulcers are found in 
the stomach, the surrounding mucous membrane is the seat of intense 
congestion, and in places there are extravasations of blood. If death is 
later there are evidences of intense inflammation, sometimes with the pro- 
duction of pseudo-membrane. If the amount of poison is not sufficient 
to cause death, and if the patient recovers from the consecutive gastritis, 
a cicatricial condition of the stomach results, which may later lead to 
stenosis of the pylorus or other deformity of the organ. 

Symptoms. — Catarrhal gastritis can not be distinguished in its begin- 
ning from an attack of acute indigestion. There are fever, pain, vomiting, 
thirst, loss of appetite, coated tongue, and prostration. The presence of 
inflammatory changes is indicated by the continuance of these symptoms, 
particularly the pain, vomiting, fever, and thirst. With the pain there 
may be epigastric tenderness. All food or liquids are immediately re- 
jected, and even when nothing is taken the retching and vomiting maj 
continue, nothing but frothy mucus or serum being brought up, some- 
times streaked with blood. The vomited matters are usually very sour ; 
they may be bilious. The temperature is high only at the outset. After 
the first or second day it usually ranges between 100° and 101-5° F. 
Thirst is intense, and all liquids are taken with avidity, especially if cold, 
even though they are immediately vomited. The tongue is thickly coated 
with a white fur, and the breath may be foul. The constitutional symp- 
toms are generally most severe at the outset. The usual duration of such 
attacks is four to seven days, but with improper management, especially 
injudicious feeding, the disease may be much prolonged. One attack may 
follow another until a chronic condition is established. In most of the cases 
there is some disturbance of the intestines, usually a sharp attack of diar- 
rhoea. Sometimes the gastric symptoms subside after a few days and those 
of the intestine become the predominant ones. The symptoms above 



296 DISEASES OP THE DIGESTIVE SYSTEM. 

given are those of infancy. In older children there is less of fever, pros- 
tration, and diarrhoea, but pain and vomiting are prominent. The attacks 
are usually shorter and altogether less severe. 

The I'are cases of follicular gastritis have nothing by which they can 
be distinguished from the form described, except a more prolonged course 
and a greater liability to haemorrhage, blood sometimes being vomited in 
quite large amounts. 

Membranous gastritis also presents no peculiar symptoms. In fact, 
in the cases I have personally seen, the gastric symptoms were insignifi- 
cant, and the condition not suspected during life. 

In corrosive gastritis the effects of the caustic may be seen in the 
mouth and pharynx, the mucous membrane being of a gray or whitish 
colour. There are felt pain and a sense of constriction in the oesophagus 
and stomach, with great thirst. Vomiting follows almost immediately, 
and the matters vomited are usually bloody. The subsequent course in 
most of the cases is the rapid development of collapse, and death in a few 
hours from shock. The younger the child the sooner does the case ter- 
minate. In irritant poisoning not severe enough to produce death, the 
symptoms of acute gastritis follow, usually accompanied by more or less 
enteritis owing to the passage of the irritant into the intestine. There is 
seen a continuance of the vomiting, pain and epigastric distention, and 
diarrhoea, and from these symptoms death may result in two or three 
days. It is extremely rare in infancy for the patient to survive both the 
stage of shock and that of acute inflammation, so that the deformities of 
the stomach and the chronic conditions mentioned, are practically never 
met with excepting in older children. 

Treatment. — Cases of acute catarrhal gastritis are to be managed very 
much like those of acute gastric indigestion. Thirst may be relieved by 
swallowing bits of ice. Where there is continuous vomiting of acid 
mucus, relief is sometimes afforded by repeating the stomach-washing 
once in twelve hours with a 1-per-cent solution of bicarbonate of soda, 
used at 110° F. In older children, beneficial results sometimes follow the 
use of bismuth subcarbonate (gr. x every two hours) ; but in infants I 
must confess to have seen but little effect from any form of medication, 
the reliance being upon rest, careful feeding, and stomach-washing. 

Cases of corrosive gastritis require special treatment. The first indica- 
tion is to administer the proper chemical antidote to the substance swal- 
lowed, and the next to use bland mucilaginous or oily fluids, such as 
milk, albumen-water, oils in large quantities, etc. Especially should stom- 
ach-washing be avoided. Opium is always required, on account of pain, 
and should be given hypodermically. The general symptoms are to be 
treated according to the indications of the individual case. 



GASTRO-DUODENITIS. 



297 



GASTRO-DUODENITIS. 

This is a catarrhal inflammation of the stomach and duodenum. 
Sometimes only the duodenum is involved. The inflammation commonly 
extends from the intestine to the common bile duct, the swelling of which 
causes jaundice. The term gastro-duodenitis is sometimes used synony- 
mously with catarrhal jaundice. The condition is a rare one in young 
children, and especially so in infancy. I have never seen it in a child 
under two years. 

The causes are for the most part obscure. It occasionally complicates 
malarial fever. I have twice seen it with influenza, and it may occur with 
any of the infectious diseases. Eehn has described a form which occurred 
epidemically. 

The symptoms of the disease are quite uniform. When primary, the 
onset is like an ordinary attack of indigestion, with vomiting, pain, slight 
fever, and a moderate amount of prostration. The vomiting in some of 
the cases is repeated for several days. The pain may be quite severe, and 
localized in the region of the duodenum. It may be associated with 
tenderness in this region. The bowels are usually constipated. After 
three or four days, icterus, which is the only diagnostic symptom, appears. 
It is first seen in the conjunctiva, afterward in the skin, varying in degree 
according to the severity of the attack, but in most cases not being very 
intense. It is accompanied by the regular symptoms of obstructive jaun- 
dice. The stools are gray, sometimes white ; there is a marked amount 
of intestinal flatulence. The urine is very dark, of a yellowish-green or 
bronze hue, and stains the clothing. There is complete anorexia; the 
tongue is thickly coated with a white fur. There are headache, dulness, 
and languor, and the patient feels generally wretched. The slow pulse 
and the itching skin are uncommon symptoms in children. The liver is 
usually found, upon examination, slightly enlarged, and sometimes tender 
on pressure. The duration of the disease is about two weeks, the general 
symptoms disappearing before the icterus. 

The diagnosis rarely presents any difficulty, and the prognosis is inva- 
riably good. 

Treatment. — In the diet, fats and starches should be reduced to a low 
point or be entirely prohibited. Patients usually do much better upon a 
diet of rare meat, fruit, and a moderate amount of milk. If there is very 
much vomiting, the milk should be largely diluted with limewater or 
partly peptonized. The amount of food given should be small, but water 
should be allowed freely, particularly the mineral waters. The bowels 
should be opened every other day by calomel, followed by a saline purga- 
tive. In most of the cases no other treatment is necessary. "When the 
pain is severe it may be relieved by counter-irritation by mustard, tur- 
pentine, or even cantharides. The gastric symptoms should be managed 



298 DISEASES OP THE DIGESTIVE SYSTEM. 

like those of ordinary acute gastritis. The restricted diet should in all 
cases be continued for at least a week after the jaundice has disappeared. 

CHRONIC GASTRIC INDIGESTION— CHRONIC GASTRITIS— GASTRIC 

CATARRH. 

Although from a pathological point of view these conditions are not 
identical, from a clinical standpoint there is no advantage in attempting 
to separate them. Nothing distinguishes chronic indigestion from chronic 
gastritis except that in the latter, in addition to continued derangement 
of function, there is a great increase in the production of gastric mucus. 
Chronic indigestion seldom exists long without the production of a slight 
amount of catarrhal inflammation. This is usually of a very low grade. 
This condition in the stomach seldom, if ever, exists without more or less 
involvement of the intestine, and in the majority of cases the intestinal 
condition is the more important. In some, however, the gastric symp- 
toms predominate, and it is only those which are here considered. 

Etiology. — Chronic gastric indigestion may follow acute attacks, or 
it may be chronic from the outset. If the latter, it depends in infancy 
upon the continued use of improper food or bad habits of feeding. It 
also complicates most of the constitutional diseases of infancy, especially 
rickets, syphilis, tuberculosis, malnutrition, and marasmus. It may follow 
any of the acute infectious diseases. In older children it is chiefly due to 
the use of improper food, sometimes to the habit of rapid eating and 
insufficient mastication. It is associated with constitutional diseases as 
in infancy, and may complicate valvular disease of the heart. 

Lesions. — The changes found in chronic gastritis are usually confined 
to the mucosa. In the mild form there are degenerative changes of the 
epithelium of the tubules, with increased production of mucus ; there 
may be a slight infiltration of the mucosa w T ith round cells. The more 
severe form, with marked cell infiltration and the production of new con- 
nective tissue, is extremely rare. The submucous coat may be thickened 
and the muscular coat attenuated. The lesion can not be recognised by 
the naked eye. The stomach is apt to appear more or less dilated, and 
its surface is coated with thick and very adherent mucus. This lesion 
rarely exists alone, practically never in infancy, but is associated with 
similar lesions in the intestines, the latter being more severe. 

Symptoms. — In infants. — For our knowledge of the conditions exist- 
ing in the stomach in chronic indigestion we are indebted to the work 
chiefly of Cassel, Leo, Troitzky, and Wohlmann. There is in most cases 
an excessive production of mucus which is tough and adherent, and may 
interfere with digestion, even though secretions are normal. Mucus is 
especially abundant in young infants. The reaction of the stomach is 
almost invariably acid. The rennet ferment is always present. Pepsin is 
found in nearly all if not in all the cases. Hydrochloric acid is generally 



CHRONIC GASTRIC INDIGESTION. 299 

very scanty ; but is increased by irrigating the stomach. Fermentation 
takes place, particularly in the fats and in the gastric mucus. The results 
of fermentation are the production of lactic, acetic, butyric and other 
volatile fatty acids. New products are also formed from the decomposi- 
tion of albumen, and gases are always present. Food remains long in the 
stomach because of motor inactivity, which is partly the cause and partly 
the result of the disease. It often continues after all other symptoms 
have disappeared. 

The most constant symptom is vomiting. This is rarely absent, and 
it may take place at any time after feeding. Some infants vomit regu- 
larly within half an hour or an hour after feeding, some only occasionally 
and at longer intervals. The vomited matters consist of food, often that 
which has been given six or eight hours before, and mucus, which may be 
in large quantities, as much as an ounce at a time. The food remains 
long in the stomach. This is best ascertained by stomach-washing. In- 
stead of being empty in two or three hours, as the stomach should be, 
food is almost invariably found four or five hours, and in some cases six 
or eight hours, after feeding. This is one of the most constant and 
conclusive signs of gastric indigestion. 

Undigested food, especially casein, appears in the stools. The appetite 
may be good or it may be very poor. As a rule, children take less food 
than in health. The tongue is usually coated ; there are signs of general 
malnutrition ; there are seen fretf ulness and irregular or disturbed sleep ; 
most children cry a great deal, but some are unnaturally quiet ; the 
weight is stationary, or there is steady loss ; there is also anaemia, and 
the child's development is arrested. There is always some derange- 
ment of the bowels, occasionally constipation, with the constant presence 
of masses of undigested food in the stools, but more frequently there is 
diarrhoea. There may be dilatation of the stomach. This is especially 
liable to occur in rachitic children where overfeeding has long been 
practised. 

The course of these symptoms is indefinite. There is little tendency 
to spontaneous recovery, and they often go on for several months, until 
some intercurrent disease develops which proves fatal. 

The prognosis depends upon the age of the patient, the duration of 
the disease, the surroundings, and upon how well treatment can be carried 
out. In infants under three months the prognosis as to life is often bad. 
If children live to the age of seven or eight months, they may recover with 
proper treatment. These patients do much better in private practice than 
in institutions. Much depends upon the co-operation of an intelligent 
mother or nurse. Chronic gastric indigestion is not dangerous to life 
except in very young infants. Its principal danger consists in the pre- 
disposition it gives to acute diarrhoeal diseases in summer. Such patients 
are almost certain to be attacked, and are very likely to succumb. It may 



300 DISEASES OF THE DIGESTIVE SYSTEM. 

also lead to the development of marasmus. Chronic indigestion increases 
very much the danger from all acute diseases. 

In older children. — In all cases the most constant symptom is vomit- 
ing, which may occur regularly after meals, or only in the morning 
before breakfast. If the latter, the vomited matters consist chiefly of 
mucus. In addition to these regular attacks there may be the frequent 
regurgitation of small quantities of food. There are gastric flatulence 
and pain, due to hyperacidity or to acid fermentation. The appetite is 
variable — sometimes inordinate, sometimes entirely lost ; it may be capri- 
cious, there being usually a craving for highly seasoned food. The tongue 
is constantly furred, and the breath usually disagreeable. These symp- 
toms are seen in all degrees of severity. Intestinal disturbances are not 
so frequent as in infancy. Constipation is more common than diarrhoea. 
The general symptoms are those of malnutrition. There are anaemia, 
wasting, constant fretfulness, disturbed sleep, and various other nervous 
disorders. These symptoms, as in the case of infants, may continue in- 
definitely; there is little tendency to spontaneous recovery, but under 
favourable circumstances, with constant care, much may be done for all 
these patients and many of them may be completely cured. 

Treatment. — Infants. — The general treatment is too apt to be ignored, 
but it is just as important as measures directed more specifically to the 
stomach. A large, roomy nursery, and plenty of fresh air by night and 
by day, are very important ; sometimes under the influence of these alone 
improvement begins. General friction of the body with cocoa-butter is 
useful in delicate children with poor circulation. Infants must be prop- 
erly covered, and it is of the utmost importance that the feet be kept 
warm. Of the measures directed to the stomach, only two are to be de- 
pended upon — stomach-washing and diet. 

Stomach- washing (page 60) is useful, first, in removing the mucus 
which is so abundant in most of these cases ; secondly, in cleansing the 
organ thoroughly at least once a day, this of itself is a most important 
result ; thirdly, as a stimulant to the gastric secretions, especially hydro- 
chloric acid. Plain boiled water, or a weak alkaline solution — sodium 
bicarbonate, one drachm to the pint — may be employed. In the early 
part of the treatment the washing should be done daily; later, every 
second or third day. The time selected is not very important, but it is 
better to make this about three hours after feeding. The mother or nurse 
may easily be taught to wash the stomach, so that it may be done as fre- 
quently and for as long a period as circumstances require. 

In the matter of diet, the general purpose should be to give the stom- 
ach as little to do as possible, throwing for the time the burden of the 
work of digestion upon the intestine. As the greatest difficulty is in the 
digestion of casein, it is usually better, in the case of a young infant — i. e., 
one under six months — to secure a wet-nurse. But this may not succeed 



CHRONIC GASTRIC INDIGESTION. 301 

as well as artificial feeding, as it is in our power to modify the food only 
to a limited extent. Where a good wet-nurse can not be obtained, or 
where even breast milk is not tolerated, cow's milk should be tried. In 
modifying cow's milk, it should not be forgotten that the fat as well as 
the casein may be a source of trouble. With the milk sugar there is 
usually no difficulty. The best results are obtained by beginning with 
such formulae as XVII or XVIII (page 176), obtained by diluting plain 
milk with a sugar solution. In these, both the proteids and fat are very 
low and the sugar relatively high. The proportions of the first two in- 
gredients may be gradually increased as the case improves. If this plan 
fails, the milk may be completely peptonized (page 148) before it is di- 
luted. Partially peptonizing is frequently no better than the above modi- 
fication used alone. In very obstinate cases whey (page 152) may be tried, 
and may be retained when even the small proportion of fat and casein 
in the formulae mentioned, causes disturbance. Often where no casein 
can be tolerated, raw beef juice or some of the beef peptones, such as 
Mosquera's beef jelly, are assimilated without difficulty, and may be used 
exclusively for days at a time. In infants over six months old some fari- 
naceous food, such as a thin gruel of barley or arrowroot, may be given 
alternately with the beef preparations ; or one of the malted foods may be 
used in the same way. Other suggestions regarding diet will be found 
in the chapter on Feeding of Difficult Cases during the First Year (page 
180). 

The quantity of food given at one time and the frequency of feeding 
are also important. Under no circumstances should an infant with 
chronic indigestion be fed oftener than once in three hours, and in many 
cases the interval for children over three months of age should be four 
hours. The bottle should always be taken away in twenty minutes after 
the meal has begun. The number of meals in a day should be the same 
as for healthy infants. The amount of food should always be rather less 
than that required by a healthy infant of the same age. It is wise to 
begin with about half the quantity, gradually increasing as the child's 
powers of digestion improve. Gavage is sometimes useful where vomit- 
ing is frequent and can not be controlled. Food administered in this 
way may be retained, when it is immediately vomited if given from the 
bottle or the spoon. 

Drugs have a very limited application in these cases. Usually they are 
too much employed. The majority of patients do better when they are 
withheld entirely. They may be useful for particular symptoms. Alka- 
lies may temporarily relieve cases with excessive acid fermentation. Small 
doses of strychnine or nux vomica may stimulate the motor activity of the 
muscular walls of the stomach. Hydrochloric acid at times may decidedly 
improve the digestion where it is given well diluted after meals ; often, 
however, it causes vomiting. Almost all the indications mentioned are 



302 DISEASES OF THE DIGESTIVE SYSTEM. 

more promptly and efficiently met by stomach-washing than by the other 
means referred to. 

The management of these cases in older children must be conducted 
along the lines laid down for infants. In them, stomach- washing can not 
be employed, and other means must be used to clear the stomach of 
mucus. The best is undoubtedly the use of large draughts of water, 
as hot as can be borne, an hour before eating. From six to eight ounces 
should be taken, preferably slowly by sipping. To this may be advan- 
tageously added, in many cases, fifteen or twenty grains of bicarbonate 
of soda. 

The diet should consist of milk diluted at least three times, kumyss or 
matzoon, beef juice, raw meat, beef peptones, and a moderate amount of 
starchy food, preferably dried bread or zwieback. Sweet fruits, and in 
many cases all fruits, must be avoided. The amount of water taken at 
mealtime should be carefully restricted. Beneficial results are obtained 
in most of these cases by the use of nux vomica or simple bitters before 
meals, and the regular administration of hydrochloric acid (gtt. v to viii 
of the dilute acid) shortly after meals. All pastry, sweets, nuts, and can- 
dies must be absolutely prohibited. With improvement in the symptoms 
green vegetables may be added to the diet, and the amount of starchy 
food increased. The general treatment must not be neglected. The 
patient should lead an out-of-door life as much as possible, and regular 
but very moderate exercise allowed. Great caution is necessary against 
overfatigue. Iron may be given in most cases during convalescence ; but 
cod-liver oil should be carefully avoided until the gastric symptoms have 
quite disappeared. Kelapses are easily excited, and the most constant care 
regarding the food must be maintained for months, or even years. 

DILATATION OF THE STOMACH. 

Moderate dilatation of the stomach is quite a frequent condition, al- 
though it is not so large a factor in the disorders of digestion in infancy 
and childhood, as many- who have written upon the subject would lead us 
to believe. A very marked degree of dilatation is rare, but in these cases 
its recognition is important and its treatment difficult. 

Dilatation is almost invariably regular or cylindrical ; it is usually most 
marked at the cardiac extremity (Fig. 48). Cases of irregular or saccular 
dilatation, except when associated with cicatricial conditions, are of some- 
what doubtful occurrence. The irregular shapes of the stomach found at 
autopsy, dependent upon the contraction of the muscular coats, may be 
easily mistaken for hour-glass contraction or saccular dilatation. The 
degree of dilatation may be very great ; thus, the stomach of a child three 
months old measured at autopsy nine ounces; another, four and a half 
months old, ten ounces ; and in one extreme case, the stomach of a two- 
weeks old baby was dilated to the capacity of seventeen ounces. The 



DILATATION OF THE STOMACH. 393 

greatest dilatation I have measured during life was in a child four months 
old, where the stomach held twelve ounces. 

In very rare instances dilatation may result from congenital stenosis 
of the pylorus. The most important predisposing cause, however, is the 
muscular atony which accompanies rickets. It is found to a slight degree 
in almost all severe cases of rickets. The principal exciting causes are 
continued distention from overfeeding and chronic indigestion. 

In most cases the only symptoms are those of the chronic indigestion 
which almost invariably accompanies dilatation. If there is pyloric steno- 
sis, vomiting is present. In young infants the pressure symptoms may be 
very serious. This is particularly true in infants with acute bronchitis or 
broncho-pneumonia, or in those with atelectasis. In these patients I have 
seen very grave symptoms accompany the rapid distention of a dilated 




Fig. 48. — A, dilated stomach from rachitic child of six months ; B, stomach of healthy child 
of same age. (Outlines reduced from photographs.) 

stomach, and in one very delicate infant of three months this was appar- 
ently the cause of death. A positive diagnosis of dilatation is only 
made by the physical signs. There are epigastric fulness and distention, 
and in some very thin patients the outline of the stomach can be distinctly 
seen. Dilatation of the transverse colon, however, may be mistaken for 
dilatation of the stomach. In the latter, the lower outline is convex, while 
in the former it is usually slightly concave. The most satisfactory means 
of diagnosis is by percussion. The examination should be made three or 
four hours after feeding, at which time the whole abdomen is apt to be 
tympanitic. The stomach should then be filled with water; the lower 
limit of the area of flatness will be the lower border of the stomach. This 
is much more satisfactory than determining the outline after the genera- 
tion of gas in the stomach. If the lower border comes nearly to the 
umbilicus the stomach is dilated ; if it is below the umbilicus, it is much 
dilated. In many cases the capacity of the stomach can be measured by 
simply seeing how much water can be easily introduced into it by means 
of the funnel and stomach tube. 



304 DISEASES OP THE DIGESTIVE SYSTEM. 

The prognosis in dilatation of the stomach is good except when it is 
due to pyloric stenosis. If the infant has any acute or chronic pulmo- 
nary disease, dilatation of the stomach may add to the discomfort and 
even the danger from that condition. 

In the management of these cases the first point is to reduce the size 
of the meals, and to regulate the diet in accordance with the general plan 
outlined in the chapter on Chronic Indigestion. If the dilatation is 
marked, the stomach should be washed once a day. The general condition 
of the patient usually requires tonics, the best of which is strychnine ; and 
rickets, if present, should receive its appropriate constitutional treatment. 

ULCER OF THE STOMACH. 

Ulceration of the stomach may be found in connection with several 
pathological processes which are quite distinct from one another : 

1. Ulcers in the newly-born. These have already been referred to in 
the chapter on Haemorrhages of the Newly-Born (page 101). The only 
characteristic symptom is haemorrhage. 

2. Ulcers resulting from follicular gastritis. These also are not fre- 
quent. As a rule they give no symptom except those of gastritis, although 
in several cases I have known severe haemorrhage to result from them. 
These cases will be considered in the next chapter. 

3. Tubercular ulcers. These are quite rare. I have met with gastric 
ulcers but five times in one hundred and nineteen autopsies on tubercular 
cases ; however, the evidence was not conclusive in all of them that the 
ulcers were tubercular. Usually there were many small ulcers ; in one 
case but two were present, the larger one being nearly three fourths of an 
inch in diameter, and situated on the posterior wall near the middle of the 
greater curvature. All but one of these cases were in infants, one child 
being only ten months old. The ulcers gave no symptoms during life, and 
death took place from general tuberculosis. This is the history of nearly 
all the few cases on record. In one, however, reported by Casin, a tuber- 
cular ulcer perforated the stomach and caused death from peritonitis. 
Active symptoms — bloody vomiting and bloody stools — were excited by the 
use of an emetic. 

(4) Eound perforating ulcers. These are in their pathology essentially 
the same as similar ulcers in the adult. I have found but three cases on 
record in non- tubercular patients. Two were in young children. Kei- 
mer's * case, three and a half years old, had bloody vomiting and stools 
for several days before death took place as a result of perforation. 
Colgan f has recently added another case in a child two and a half years 
old, where no symptoms were present until twelve hours before death, 

* Jahrb. f iir Kinderh., x, p. 289. 

t Medical News, Philadelphia, October, 1892. 



HAEMORRHAGE FROM THE STOMACH. 305 

when perforation occurred. The characteristic symptoms of ulcer before 
perforation, are gastric pain and tenderness, vomiting of blood, and often 
bloody stools. Perforation is accompanied by collapse, sometimes by high 
temperature, the rapid development of tympanites, and death from shock 
or from peritonitis. 

The prognosis is bad in all forms of ulcer of the stomach, except the 
small follicular variety. In this, however, the diagnosis can not positively 
be made excepting by gastric haemorrhage, and it is only this which makes 
these cases serious. 

Treatment. — The treatment is absolute rest, ice, small doses of opium, 
rectal feeding, stimulants ; later, bismuth, arsenic, or nitrate of silver. 

HEMORRHAGE FROM THE STOMACH (H^EMATEMESIS). 

The most frequent variety of haemorrhage from the stomach, that met 
with in the newly-born, has already been considered. (See page 103.) 

I have met with three fatal cases in young infants, the eldest being 
fifteen months old. In the first case there were symptoms of ordinary 
gastroenteritis. On the seventh day the vomiting of blood began, and 
was repeated about ten or twelve times during the next twenty-four hours, 
when death took place. The blood was quite abundant, as much as a 
drachm of red blood being discharged at once. At autopsy there were 
found in the stomach about two ounces of dark-brown fluid, but no gross 
lesion was discovered, and no explanation of the bleeding. This haemor- 
rhage was apparently capillary. In the second case there were symptoms 
of acute gastro-enteritis of thirty-six hours' duration. After this time 
there was marked abdominal distention with symptoms of collapse ; then 
a profuse haemorrhage from the stomach, the child dying while vomiting 
blood. At least half a pint was discharged. The stomach contained at 
autopsy two ounces of dark fluid blood, and the mucous membrane was 
filled with minute ulcers extending quite through the mucosa. In the 
third case there was no vomiting of blood, but the patient died with symp- 
toms of internal haemorrhage. There was blood in the upper part of the 
intestine, and the stomach was filled with blood ; it contained many small 
follicular ulcers resembling those found in the previous case. 

Haemorrhage from the stomach may occur in purpura, haemophilia, 
scurvy, and rarely in malaria. In young girls about puberty it may be a 
form of vicarious menstruation. Occasionally blood may be vomited in 
cases of haemorrhagic measles. Two cases are reported in which fatal 
haemorrhage followed the swallowing of a foreign body. In both, vomiting 
of blood occurred long after the original accident. In one case two and 
a half years had elapsed. The autopsy in this case showed impaction 
of the foreign body and ulceration into the arch of the aorta. Spurious 
haemorrhages may occur where blood has been swallowed and then vomited. 
The source of this is most frequently the nose or pharynx. It may hap- 
25 



306 DISEASES OP THE DIGESTIVE SYSTEM. 

pen in infants at the breast, where the blood is drawn during nursing from 
a fissure or ulcer in the nipple. The amount of blood vomited under 
these circumstances may be large enough to be quite alarming. It may 
be recognised by the child's general condition being normal, and by the 
presence of fissures or ulcers upon the nipple. It may sometimes be 
noticed that the vomiting of blood follows nursing from one breast and 
not from the other. 

Symptoms. — There may be no symptoms except those of internal haem- 
orrhage, but this is rare. Usually there is vomiting of blood, and blood 
appears in the stools. If the haemorrhage is rapid and vomiting speedily 
occurs, the blood may be of a bright red colour. If it has been long in the 
stomach it is of a dark-brown or black colour resembling coffee-grounds. 
The stools containing blood from the stomach are black and tarry in 
appearance. The general symptoms will depend upon the amount of 
blood lost. 

In a case where blood is vomited, the first point is to distinguish spu- 
rious from true gastric haemorrhage. The nose and pharynx, especially its 
posterior wall, must be carefully examined. If the child is at the breast, 
the nipples should be scrutinized. In older children it is important to 
distinguish vomiting of blood from haemoptysis. This distinction is to 
be made in accordance with the rules laid down in text-books on adult 
medicine. The prognosis is bad if the hemorrhage is due to ulcer, if it is 
very profuse, or if it occurs in young infants. When it occurs in connec- 
tion with constitutional diseases the prognosis depends upon the original 
disease. 

Treatment. — The patient should be kept quiet, preferably upon the 
back, and Monsel's solution administered in small doses, largely diluted. 
Should the patient show signs of collapse, stimulants may be given hy- 
podermically or by the rectum. No food should be given by the stomach 
until some time after the haemorrhage has ceased. 



CHAPTER VI. 
DISEASES OF TEE INTESTINES. 

MALFORMATIONS AND MALPOSITIONS. 

Malformations are not very frequent, but are of great variety. With 
the exception of those situated at the lower end of the intestine they are 
not of much practical importance, for the condition is such ordinarily as 
to be incompatible with life. They may be met with at any point in the 
canal, but most frequently they are in the rectum and anus. Aside from 



MALFORMATIONS OF THE INTESTINES. 



307 




R 



-Malformations of the rectum 
K, rectum. 




these, malformations of the large intestine are much less common than 
those of the small intestine. 

Malformations of the Rectum. — In Fig. 49 are shown the usual varieties 
of malformation of the rectum. The most frequent is atresia ani (1). 
In this the cutaneous septum has not been absorbed, but the intestine is 
normal to its lower extremity. This form is readily curable by a surgical 
operation. In the next variety (2) the cutaneous orifice and the lower 
part of the rectum are nor- 
mal, but a membrane sepa- 
rates this portion from the 
upper part of the gut. This 
is usually situated within two 
or three inches of the anus. 
The bulging of the lower part 
of the distended intestine can 
usually be felt by the finger 
in the rectum, and a simple 
division of the membrane by 
a guarded bistoury may relieve 

the condition. The third form (3) is more serious. Here the rectum 
terminates in a blind pouch at a variable distance from the anus, and is 
represented below by an impervious fibrous cord. The diagnosis of this 
condition can not positively be made without opening the abdominal 
cavity. The bulging of the intestine appreciable by the finger in the 
rectum, is the only point which differentiates the preceding variety from 
this one. Instead of atresia of the rectum there may be stenosis of varying 
degrees, which may give rise to the usual symptoms of stricture. This 
is often curable by dilatation. 

Malformations of the Small Intestine. — There may be stenosis or 
atresia at any point, often at many points. Obstruction is much more 
frequently in the upper than in the lower part of the small intestine, the 
most common seat being the duodenum. Atresia is more often seen than 
stenosis. There may be a single point of obstruction, or the lumen of 
the intestine may be obliterated for a considerable distance, the intestine 
being represented only by a fibrous cord which connects the two open por- 
tions, or there may be no connection between them. In all cases the in- 
testine above is found very greatly distended, and that below empty and 
usually atrophied. The causes of these multiple deformities are mainly 
two — fcetal peritonitis and volvulus.* In foetal peritonitis there are 
usually found bands of adhesions between the intestinal coils, and between 



* Silbermann (Jahrb. f iir Kinderh., Bd. xviii, p. 420) makes peritonitis the princi- 
pal cause, while Gaertner (Jahrb. fur Kinderh., Bd. xx, p. 403) attributes most of these 
deformities to volvulus. 



308 DISEASES OF THE DIGESTIVE SYSTEM. 

the intestine and the solid viscera. Syphilis has been assigned as a cause 
in many cases. Volvulus, or a twisting of the intestine during its devel- 
opment, is a more satisfactory explanation for the majority of the cases, 
especially where there are multiple points of atresia. All these conditions 
are beyond the reach of surgical treatment. The symptoms appear soon 
after birth and are those of intestinal obstruction. (See page 115.) The 
higher the point of obstruction the shorter the duration of life ; it is 
rarely more than a week in any case of atresia ; in stenosis it may be two 
or three months. 

Meckel's diverticulum: — This is the remains of the omphalo-mesenteric 
duct, which in foetal life forms a communication between the intestine 
and the umbilical vesicle. It is given off from the ileum, usually about a 
foot above the ileo-cascal valve. Most frequently this exists as a blind 
pouch from one half to two or three inches long, communicating with the 
intestine. At the extremity of this there may be a fibrous cord, which 
may be free in the abdominal cavity or attached to the umbilicus. In 
other cases the duct may remain pervious to the umbilicus, so that there 
is a faecal fistula. Prolapse of the mucous membrane of the duct may 
lead to an umbilical tumour. (See page 112.) Meckel's diverticulum, 
especially when present as a cord connecting the ileum to the umbilicus, 
may compress a coil of intestine, leading to obstruction or even strangula- 
tion. This may occur in infancy or later in life. 

Malpositions. — The ascending colon may be found upon the left side. 
There may be a complete transposition of the abdominal viscera. In cases 
of congenital umbilical hernia a large part of the intestines may be found 
in the tumour, and in diaphragmatic hernia they may be in the thoracic 

cavity. 

DIARRHCEA. 

The term diarrhoea is used to cover all conditions attended by frequent 
loose evacuations from the bowels. These depend upon an increase in 
peristalsis and in the intestinal secretions. There are certain etiological 
factors which are common to all forms of diarrhoea. 

Age. — A peculiar susceptibility exists in very young children. This is 
well brought out by the following statistics. My associate, Dr. Crandall, 
has tabulated three thousand cases of diarrhoea, including those treated 
by both of us in private and dispensary practice, and others from the 
records of two large dispensaries in New York. The ages of those apply- 
ing for treatment were : under six months, 14 per cent ; six to twelve 
months, 29 per cent ; twelve to eighteen months, 24 per cent ; eighteen to 
twenty-four months, 17 per cent ; over two years, 16 per cent. It will be 
noted that the greatest susceptibility is between six and eighteen months, 
and that over four fifths of all the cases occurred during the first two years. 

Season. — The next striking fact about diarrhceal diseases is their prev- 
alence during the summer season. This is graphically shown in Figs. 



DIARRHCEA. 



309 



50 and 51, where are given by months the cases treated in a large New 
York dispensary for ten years, and the mortuary records for the entire 
city during the same period. The enormous increase in the number of 



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315 289 359 403 660 4103 12,468 6205 3641 1723 548 324 

Fig. 50. — Mortality from diarrhoeal diseases in New York for ten years in children under five- 

compared with the mean temperature for the same period. , mortality ; j 

mean temperature. (Seibert.) 

cases occurring in the summer months does not have reference to any 
single form of diarrhoea, but to all forms. The significance of these facts 
will be considered later. 

Surroundings. — While diarrhoeal diseases are especially frequent in 
cities and among the poor, still they are not essentially diseases of the 
city nor of poverty. Severe and even fatal cases are constantly met with 
among all classes and in all places. Sufficient evidence has not yet accu- 



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Fig. 51. — Cases of diarrhoeal disease treated in the German Dispensary (New York) in ten 
years in children under five ; compared with the mean temperature for the same period. 
, cases of diarrhoea ; , mean temperature. (Seibert.) 

mulated to establish a direct connection between a polluted atmosphere and 
the prevalence of diarrhoeal diseases. They are not essentially filth- diseases ; 
yet their frequency and severity are both increased by want of cleanliness in 
apartments, in the persons and clothing of infants, especially the napkins, 



310 DISEASES OP THE DIGESTIVE SYSTEM. 

chiefly, it appears, as these lead to a contamination of the food. Vacher 
has shown that the mortality from diarrhoea in the large English towns 
had no constant relation to the density of population. Poverty, neglect, 
and bad surroundings, predispose to diarrhoea in summer, just as they do 
to other forms of acute disease in the cold season. 

Constitution. — Everything which lowers the general vitality increases 
the liability to diarrhceal diseases. Children suffering from marasmus, 
malnutrition, syphilis, rickets, or tuberculosis are especially prone to be 
affected, and these make up the bulk of the fatal cases in cities. 

Dentition. — There are cases in which diarrhoea and dentition are 
closely associated, for the bowels quickly become normal when the teeth 
have pierced the gum. These, although rare, do occur. Too much, how- 
ever, can not be said in contradiction of the wide-spread belief among the 
laity that diarrhoea accompanying dentition is normal or even beneficial. 
The infrequency of diarrhoea during dentition in the cold season, is the 
best argument against its importance as an etiological factor. 

Food and feeding. — Of 1,943 fatal cases which I have collected, only 
three per cent had the breast exclusively. In my own experience fatal 
cases of diarrhceal disease in nursing infants are extremely rare. These 
are significant facts. They show that the manner of feeding is one of 
the most important factors in the production of diarrhoea. This is to be 
connected with the statistics with reference to age. The poor in New 
York are wont to nurse their infants exclusively for about six months. If 
nursing is continued longer, it is usually with the addition of other food, 
often of the most indigestible kind. Children among the poor in tene- 
ments enjoy immunity from intestinal disease just in proportion as they 
are breast-fed, and just so long as they are so ; but as soon as artificial 
feeding is begun, diarrhoeal diseases are prevalent. There are many rea- 
sons for this. In most cases, however, it is not artificial feeding per se, 
but artificial feeding ignorantly and improperly done, which is to be 
blamed. If cow's milk is employed as a substitute for breast-milk, the 
differences in composition are either not appreciated or else ignored, so 
that many artificially-fed children suffer from malnutrition. The com- 
parative safety of cow's milk in winter and in the country, however, shows 
that the difference in chemical composition is not the most important one. 
A common and very serious mistake is that of over-feeding. Artificial- 
ly-fed children are almost always over-fed. The common practice of feed- 
ing an infant every time it cries, or of keeping the bottle at its mouth the 
greater part of the time, is productive of untold harm. 

The feeding of impure or contaminated milk is an important cause of 
diarrhoea, especially among the poor in cities during the summer. The 
condition of the milk may be due to disease in the cow, to adulteration or 
pollution at the dairy, during transportation, or in the homes. It may 
come from dirty vessels in which the milk is kept, or dirty bottles from 



DIARRHCEA. 311 

which it is fed. In some cases the milk may be the vehicle of specific in- 
fection. In others, its condition is owing to the ordinary fermentation 
changes due to the age of the milk — it being often two and sometimes 
three days old before it is consumed, and very often kept with little or 
no ice. It is surprising to see how quickly diarrhoea is excited by impure 
milk. I once saw in the Xew York Infant Asylum every one of the 
twenty-three healthy children, all over two years old and occupying one 
ward, attacked in a single day with diarrhoea which was traced to this 
cause. Articles of food totally unsuited to the child's digestion are often 
given. Among the poor it is a common practice to give all kinds of solid 
food to children from twelve to eighteen months old, while those of two 
years often get only the regular diet of the family. The great majority of 
the attacks of diarrhoea in children over two years old can be traced di- 
rectly to improper food. 

The factors mentioned — over-feeding, too frequent feeding, and the 
habitual use of improper food — all combine to produce a chronic indiges- 
tion which is probably the most important predisposing cause of diar- 
rhceal diseases. 

The Different Varieties of Acute Diarrhoea. — Mechanical diarrhoea. — 
This includes cases in which diarrhoea is produced by foreign bodies, or 
substances taken as food which virtually act as foreign bodies : such are 
partly-cooked rice or other cereals, dried fruits, or fresh fruits containing 
seeds ; green corn, radishes, celery, cabbage, or other vegetables ; nuts and 
unripe fruits. The irritation caused by such substances may produce only 
increased secretion and peristalsis by which the offending articles are re- 
moved, or, if sufficiently severe and continued, it may lead to actual in- 
flammation of the mucous membrane of the intestine. 

The indications for treatment are first to give an active cathartic — 
castor oil, calomel, or a saline — and, after thorough evacuation of the 
bowel has taken place, to quiet the excessive irritation by opium. The 
particular preparation used is not important. For two or three davs 
after such an attack the diet should be very light, and of such a character 
as to leave but little residue — e. g., for infants, broth, beef juice, white of 
egg ; and for older children, diluted milk or kumyss. The patient should 
be kept quiet, preferably in bed, until the stools are quite normal. The 
neglect of such mild attacks is a frequent cause of more severe ones. 

Diarrhoea from drugs. — In susceptible infants any of the ordinary 
cathartic drugs may cause an attack of diarrhoea, because the phvsiological 
effects have been either exaggerated or prolonged. It is doubtful whether 
such attacks are often produced in nursing infants by cathartics taken by 
the nurse. The organic acids contained in fruits may operate in the same 
way as cathartic drugs. In cases like these the diarrhoea is readily con- 
trolled by opium, usually by small doses, which should be repeated after 
each action of the bowels. 



312 DISEASES OF THE DIGESTIVE SYSTEM. 

D iarrhcea from nervous influences. — Certain nervous impressions seem 
to be able to produce diarrhoea where no other factors are present. Some- 
times these act in conjunction with other causes. The most important 
are chilling of the surface, depression caused by atmospheric heat, fatigue, 
exhaustion, fright, and dentition. Diarrhoea may be seen in older chil- 
dren with anaemia, chorea, and general malnutrition. It is a characteristic 
of many of these cases, that the taking of food into the stomach immedi- 
ately excites a movement of the bowels. The stools usually contain undi- ■ 
gested food, because the intestinal contents are so rapidly hurried forward. 
The chief abnormal condition in such cases is exaggerated peristalsis. 
This is best controlled by rest and opium ; small doses only are usually 
required. 

Eliminative diarrhoea. — This term has been applied to cases in which 
diarrhoea is evidently an effort on the part of Nature to rid the blood of 
some irritant or toxic element. The best-known example is the diarrhoea 
of uraemia. It is, however, very probable that the diarrhoea of many acute 
infectious diseases belongs in this category. The danger of suddenly ar- 
resting such a discharge is a real one. It should be closely watched, and 
not allowed to become in itself a drain upon the patient, but checked 
only when excessive. 

Acute intestinal indigestion. — Diarrhoea is a constant symptom of this 
condition, which is of such importance that it will be considered at 
length. The exciting cause of the diarrhoea may be either the mechanical 
irritation of particles of undigested food, or the various putrefactive prod- 
ucts which take place from the decomposition of such food. This form 
is especially severe in infancy, and is usually accompanied by high fever 
and other marked constitutional symptoms. Gastric symptoms are pres- 
ent in most of the cases. 

In the forms of diarrhoea above enumerated there are no lesions, and 
the bacteria found in the stools are the ordinary bacteria of the intestines. 
All other forms of acute diarrhoea are to be regarded as infectious, the 
infection starting from the intestinal contents. All of them also are as- 
sociated with lesions, the severity of which depends upon the nature and 
degree of the infection, and the duration of the process. In the mildest 
cases and in those of short duration, the lesions involve only the superficial 
epithelium. In these the symptoms are due not so much to the anatom- 
ical changes, as to functional derangement and the presence of toxic ma- 
terials in the intestine ; some of these act locally and others produce con- 
stitutional symptoms by absorption into the general circulation. These 
have been classed as cases of acute gastro-enteric infection. 

In the more severe forms, and in those of longer duration, the lesions 
may involve the entire mucosa, or they may extend into the submucosa 
quite to the muscular coat. They vary greatly in character as well as in 
degree. The lesions are very important, as modifying the symptoms, 



ACUTE INTESTINAL INDIGESTION. 313 

course, and termination of these cases. For this reason they are some- 
times classed as cases of inflammatory diarrhoea ; here, from the position 
of the lesions, they are grouped under the term ileo-colitis. 

According to Booker's observations, the bacteria usually associated 
with the superficial lesions are bacilli; those with the deeper lesions, 
streptococci. 

The pathological relation existing between the different forms of diar- 
rhceal disease is a very close one. The same case may pass successively 
through the stages of acute indigestion, gastro-enteric infection, and ileo- 
colitis. This transition may be very slow, or it may be so rapid that the 
different stages can not be distinguished. Instead of passing through the 
entire series, the process may stop at any stage and the case recover, or it 
may at any stage prove fatal. 

ACUTE INTESTINAL INDIGESTION. 

In infants, acute indigestion is seldom limited either to the stomach or 
to the intestine, although in one case the disturbance of the stomach is 
slight and that of the intestine serious, and in another the reverse may be 
observed. In these little patients the intestinal symptoms are much more 
frequent, and as a rule they are more severe than those referable to the 
stomach. There will be considered in this connection only the intestinal 
symptoms of acute indigestion ; the gastric symptoms have been described 
on page 291. It should be remembered that these may be seen in all possi- 
ble combinations. In older children it is hot uncommon to see the intes- 
tinal symptoms alone. 

Etiology. — The causes are essentially the same as those mentioned 
under Gastric Indigestion — the use of improper food, over-feeding, sudden 
change of food as in weaning, and various conditions affecting the nerv- 
ous system, such as heat, cold, fatigue, or the onset of any acute disease. 
A predisposition to such attacks is furnished by summer weather, a deli- 
cate constitution, and especially by a feeble digestion. This predisposition 
is greatly increased by previous attacks of acute or chronic indigestion or 
intestinal inflammation. In susceptible children, both infants and those 
who are older, the slightest error in feeding may induce an attack. 

Symptoms. — In infants, if the attack develops suddenly, gastric symp- 
toms are usually present ; if more gradually, they are usually absent. The 
local symptoms are colicky pain, tympanites, and diarrhoea. The impor- 
tant constitutional symptoms are fever, prostration, and various nervous 
disturbances. In older children the pain generally precedes the diarrhoea 
by some hours, and is referred to the region of the umbilicus. In infants, 
pain is indicated by the sharp, piercing cry, great restlessness, and drawing 
up of the legs. Tympanites is rarely very marked, and may be wanting. 

The stools are always increased in number and are from four to twelve 
a day. If more frequent they are very small. The first stools are more or 



314 DISEASES OF THE DIGESTIVE SYSTEM. 

less faecal, but this character is soon lost. In infancy the colour is first 
yellow, then yellowish-green, and finally often grass-green. Wegscheider 
has shown that this colour is due to biliverdin. The exact nature of the 
process in the intestine, in consequence of which biliverdin takes the place 
of bilirubin as the colouring matter of the stools, is still a disputed point, 
but in infancy this change in colour is nearly constant. The reaction of 
the stools is almost invariably acid. The odour may be sour, or it may be 
very foul. The stools are thinner than normal, and after a few hours 
usually become almost fluid. Blood is not present, nor is mucus seen, 
unless the symptoms have lasted several days. Undigested food is always 
present ; in infants upon a milk diet, this is seen as fat or lumps of casein. 
Fat may appear as small, yellowish- white masses resembling casein, but 
distinguished by their solubility in equal parts of alcohol and ether. 
Casein masses are more numerous, larger, and whiter. Unchanged starch 
may be recognised by the iodine reaction. The microscope shows, in ad- 
dition to food-remains, mucus, epithelial cells, and bacteria. Epithelial 
cells, usually of the cylindrical variety, are numerous in proportion to the 
severity and duration of the attack. The bacteria are the ordinary forms 
found in the faeces (Booker). 

In the cases with sudden onset the temperature is invariably elevated. 
In infants it ranges from 102° to 105° F. ; in older children from 100° to 
103° F. The high temperature does not continue. Usually after twelve 
or twenty-four hours it falls nearly or quite to normal. In the cases with 
a more gradual onset, or those of a less severe character, the temperature 
does not often go above 101° F. The general prostration, like the tem- 
perature, is greatest in infants and in the cases beginning abruptly. It 
is sometimes so severe as to threaten life. There are rapid pulse, pallor, 
drawn features, and general muscular weakness. There may be restless- 
ness, due to pain and the general discomfort, or there may be dulness, 
apathy, or convulsions. 

The course and termination of the disease depend upon the previous 
condition of the patient, the nature of the exciting cause, and the treat- 
ment employed. In a previously healthy child, if the cause is at once re- 
moved and proper treatment instituted, the severe symptoms rarely last 
more than a day or two, and in four or five days the patient may be quite 
well. In delicate infants, a severe attack of acute intestinal indigestion in 
the hot season, is likely to prove the first stage of a pathological process 
which may continue until serious organic changes in the intestine have 
taken place. This result may not follow the first attack, but one is often 
succeeded by others until it occurs. If circumstances are such that proper 
dietetic treatment and general hygienic measures can not be carried out, 
this termination is very common. 

Diagnosis. — It is impossible to recognise an attack of acute intestinal 
indigestion until the diarrhoea begins ; the previous symptoms of fever, 



ACUTE INTESTINAL INDIGESTION. 315 

prostration, etc., are seen in many infantile diseases. From the other 
forms of diarrhoea, this is distinguished by its brief duration, although its 
symptoms may be very threatening. The nervous symptoms are usually 
less marked than in gastro-enteric infection, and vomiting is not so fre- 
quent. 

Prognosis. — Such attacks do not endanger life except in very young 
or very delicate infants, in whom they may be fatal. The worst feature of 
most cases is that such attacks predispose to more serious intestinal dis- 
eases, many of which have their origin in acute indigestion which has 
been either neglected or badly managed. 

Treatment. — The same general plan is to be followed as in cases of 
gastric indigestion— viz., first, to empty the bowels as completely as pos- 
sible of all decomposing or irritating masses of food ; secondly, to secure 
to the patient, and especially to the digestive organs, as complete rest as 
possible. For the first indication nothing is better than calomel, which 
may be given in one-fourth-grain doses, and repeated every hour until 
the full effect is seen. Any other active purge, such as castor oil or 
syrup of rhubarb, may be substituted. Thirst is always great on account 
of the fever and the loss of fluid by the stools, but digestion even in the 
stomach is feeble, and often arrested altogether. For the first twenty-four 
hours no plan succeeds better than that of withholding everything in the 
shape of food, giving only such articles as whey, albumen-water, mineral 
waters, or cold boiled water. Small quantities must be given — i. e., one to 
four teaspoonf uls — but the interval may be as short as ten or fifteen min- 
utes. If the prostration is very great, stimulants may be needed. Brandy 
is the best form of administration. After the offending materials have all 
been swept from the intestine, but never before, opium may be given in 
doses large enough to control the excessive catharsis. For a child a year 
old, one quarter grain of Dover's powder after each stool is usually suffi- 
cient, and often a smaller dose may answer the purpose. 

The difficult problem is to feed these cases during the latter part of 
the attack. In nursing infants, the breast may be begun after twenty-four 
hours, the nursing interval being six hours, and the time of one nursing 
being not longer than five minutes. Between the nursings other food 
may be given. In the case of infants past the nursing age, or those who 
are being artificially fed, cow's milk must be withheld in all forms for at 
least three days, and then given greatly diluted. For infants under six 
months, not more than one part of milk to seven of water should be em- 
ployed. Milk sugar, in the proportion of one even tablespoonful, should 
be added to each eight ounces of food. Such a mixture has the following 
composition : fat, - 4 per cent; sugar, 5*0 per cent; proteids, 0*5 per cent. 
In some cases it is necessary to use even so great a dilution as one part o£ 
milk to twelve of water, and one tablespoonful of the milk sugar to each 
ten ounces of food. This contains approximately : fat, 0'25 per cent ; 



316 DISEASES OF THE DIGESTIVE SYSTEM. 

sugar, 4-0 per cent; proteids, 0-3 per cent. With improvement, the 
proportions of the fat and proteids must be very gradually increased, 
as for some time the digestion is easily disturbed. In some cases there 
is an advantage in using partly or completely peptonized milk (page 
148). 

The diet of older children in the acute stage should be much like that 
of infants. Later it should consist of meat, broths, eggs, milk, and a 
small quantity of dried bread. All cereals, vegetables, and especially all 
fruits, should be withheld for some time, and when given should be 
allowed only in small quantities, and the effect on the stools watched. 
Kumyss and matzoon are frequently better borne than plain milk. 

The use of drugs in these attacks, except those already referred to as 
indicated during the early stage, seems to me to influence the disease very 
little. Sometimes good results follow the giving of the extractum pan- 
creatis half an hour after meals, or of some of the preparations of malt 
when farinaceous food is first allowed. If the diarrhoea following the acute 
symptoms is prolonged or excessive, it usually indicates that either intes- 
tinal infection or inflammation is present, and the case should be treated 
accordingly. General measures, such as rest, frequent bathing, fresh air, 
and change of air, are very important in the management of all these cases, 
especially when they occur during the summer. 



CHAPTER VII. 

DISEASES OF THE INTESTINES.— {Continued.) 

ACUTE GASTRO-ENTERIC INFECTION. 

Synonyms: Summer diarrhoea, gastro-intestinal catarrh, gastro-enteritis, cholera 
infantum, mycotic diarrhoea. 

This is the form of diarrhoea which is so prevalent in summer. It 
occurs regularly each season as an epidemic in most large cities of the 
temperate zone, the lesions in the intestines are slight, amounting in most 
cases only to a superficial catarrhal inflammation, often bearing no relation 
to the severity of the symptoms which are mainly due to the absorption 
of toxic materials, the result of the putrefactive changes in the stomach 
and intestine. This form of diarrhoea may follow closely upon an attack 
of acute indigestion, in which it very often has its beginning. When the 
infection is of sufficient intensity and duration, it leads to the develop- 
ment of marked structural changes in the intestine, especially in the lower 
ileum and the colon. Acute gastro-enteric infection thus stands midway 
between acute indigestion and ileo-colitis. 



ACUTE G ASTRO-ENTERIC INFECTION. 3X7 

Etiology. — Among the causes of acute gastro-enteric infection are to 
be mentioned, first, those which give rise to acute indigestion, and, sec- 
ondly, the general factors mentioned as predisposing to all forms of diar- 
rhoea! disease — age, surroundings, constitution, food, and methods of feed- 
ing. (See page 310.) The most striking thing about these cases is their 
prevalence during hot weather; hence this feature demands a closer ex- 
amination. While all varieties of diarrhoea are more frequent in summer, 
it is the form under consideration which is especially prevalent. Year 
after year are repeated in New York the conditions which are graphically 
represented in the charts on page 309 — viz., an epidemic which begin- 
ning in June rapidly increases in severity reaching its height in July, 
from which time it diminishes steadily during August and September, 
regularly coming to an end in October. What is true of New York is also 
true of Philadelphia, Baltimore, and other large American cities, as well 
as of Berlin and other cities of central Europe. A study of these charts 
shows that while the mean temperature rises gradually during April and 
May, it is not until June is reached with its mean temperature of 61° F., 
that any notable increase in diarrhoeal diseases begins. It appears then 
that an average mean temperature, or, according to Seibert, an average mini- 
mum temperature, of about 60° F. is needed to start the epidemic. Not 
many cases are seen until such a temperature has lasted for some days, 
usually about a week. The epidemic then begins in force and increases 
in severity through July. The explanation of the high mortality of this 
month appears to be, not the 4° or 5° F. by which the temperature of July 
exceeds that of June and August, but that the majority of the susceptible 
infants are unable to withstand the first very hot month. Humidity and 
rainfall, according to the careful investigations of both Seibert in New 
York and Baginsky in Berlin, do not influence either the prevalence of 
summer diarrhoea or its mortality. 

' The action of heat in producing diarrhoea was formerly regarded as a 
direct one. The worst cases were looked upon as examples of heat-stroke 
or thermic fever. There is no doubt that the constitutional depression 
produced by high atmospheric temperature may seriously interfere with 
digestion, and that sometimes the thirst which excessive perspiration 
produces may lead to the giving of too much food, which also may be 
a cause of indigestion. While this explanation may be satisfactory for a 
small proportion of the cases, it is not adequate for the great majority. 
The view almost universally held at the present time regarding summer 
diarrhoea is that it is of infectious origin. The grounds for this opinion 
are briefly as follows : A certain temperature is required, which is the 
same as that at which the growth of bacteria begins to be very active. 
This disease prevails to the extent to which other food than breast-milk 
is given to infants. Thus it affects infants after weaning, and those 
younger who are partly or entirely fed upon cow's milk, or at least who 



318 DISEASES OF THE DIGESTIVE SYSTEM. 

are not nursed. Cow's milk, as ordinarily handled, contains in summer 
an enormous number of bacteria (page 144), which increase directly with 
the age of the milk and the height of the temperature at which it is kept. 
It has been shown by Vaughan and others that certain substances may be 
produced in milk which are capable of exciting in animals all the symp- 
toms of severe cases of cholera infantum. In the milk which children 
had been taking when such symptoms developed, the same toxic substances 
were found. The two diseases to which summer diarrhoea has the closest 
analogy — typhoid fever and cholera — are both due to a specific infection. 

During the past few years extended bacteriological studies of the 
intestinal discharges in these cases have been made, particularly by 
Booker (Baltimore) and Baginsky (Berlin). The results thus far ob- 
tained have failed to establish the connection between any single form 
of bacteria and any variety of diarrhoea. The forms most frequently 
associated with cases of the cholera-infantum type belong to the proteus 
group. The varieties found in the other cases have been chiefly the 
ordinary saprophytic bacteria, prominent among which is the hay-bacillus 
(Fliigge). These germs gain entrance to the body, in the great majority 
of cases, through milk, although it is possible that water may sometimes 
be the vehicle. Whether they may be taken in with the inspired air is very 
questionable. In most of the cases it is probably the living bacteria which 
enter the body, while in others the symptoms are produced by taking food 
in which poisonous products have already been formed by the action of 
bacteria. The latter seems to be the explanation of some of the cases in 
which symptoms come on almost immediately after the ingestion of con- 
taminated milk. 

The acceptance of the view of the infectious character of summer diar- 
rhoea, brings up the interesting question of direct contagion. With our 
present knowledge we can not believe that this is often, if it is ever, the 
way in which this disease is spread. When occurring in institutions or 
in families, it usually happens that a number of cases are attacked simul- 
taneously rather than successively, this indicating a common cause, usually 
to be found in the food, for all. However, we know enough about the 
spread of typhoid fever and cholera from faecal discharges, to appreciate 
the importance of careful disinfection of all stools and napkins, particu- 
larly in institutions. 

Relation of the different etiological factors. — The predisposition to 
attacks of summer diarrhoea is partly general and partly local. The gen- 
eral influences are age (under two years), feeble constitution, unhygienic 
surroundings, and a condition of general malnutrition dependent upon 
improper food or feeding. The most important of the local causes is a 
chronic derangement of digestion, usually the result of improper feeding. 
In addition there may be present a low grade of catarrhal inflammation. 
The exciting cause of an attack may be acute indigestion. In conse- 



ACUTE GASTRO-ENTERIC INFECTION. 319 

quence of an arrest of digestion, there is left in the stomach and intestines 
food which readily undergoes decomposition ; and at the same time there 
are furnished conditions in which bacteria may develop, which, though 
previously present, were unable to gain a foothold ; or bacteria may be 
introduced in such numbers and of such virulence as to overpower the di- 
gestive organs ; or, finally, bacterial products may be ingested with the 
food, requiring only absorption to produce their effects. 

Lesions. — The statements which follow are based upon a study of forty 
autopsies, in twenty-two of which microscopical examinations were made. 
The lesion may be briefly described as a superficial catarrhal inflammation 
affecting the entire gastro-enteric tract, although it varies much in severity 
in the different regions and in the different cases. The colon, the lower 
ileum, and the stomach, are apt to suffer most, the duodenum and the 
jejunum least. 

The gross appearances. — These are usually disappointing, and may 
often show but little that is abnormal. The stomach is distended with 
gas, and contains undigested food. Its walls may be coated with mucus. 
The upper part of the small intestine is empty. The lower portion con- 
tains particles of food, and yellow, gray, or green materials, often offensive, 
resembling the stools passed during life. The transverse colon, the caecum, 
and sigmoid flexure are apt to be distended with gas, and contain materials 
similar to those mentioned, while the rest of the large intestine is usually 
empty and its walls contracted. It may be coated with mucus. The 
mucous membrane of the stomach may show intense congestion, gener- 
ally in patches, or it may be pale. The mucous membrane of the small 
intestine may be pale throughout ; there are often irregular areas of con- 
gestion, or a very intense congestion of a large part of its surface, par- 
ticularly in the ileum. With this there may be redness and swelling of 
Peyer's patches and the lymph nodules (solitary follicles). In the colon 
the mucous membrane is congested, especially upon the rugae. This con- 
gestion may be general or in patches. The lymph nodules are usually 
swollen; but this may be due to an antecedent process, and not to the final 
attack. There is no thickening of the intestinal walls. The changes de- 
scribed are not at all uniform, and do not differ very greatly from the 
appearances often seen in the intestines when patients have died of other 



In the cases classed clinically as cholera infantum, the pathological 
changes are more characteristic. The greater part of the small intestine, 
and sometimes the entire colon, are distended with gas, and contain ma- 
terials of a grayish -white colour about the consistency of a thin gruel. It 
has a mawkish odour, but usually not a very offensive one. The mucous 
membrane of the entire intestinal tract has in most cases a pale, " washed- 
out" appearance. Sometimes this is seen only in the small intestine, 
while there are areas of congestion in the colon. If cholera infantum has 



320 DISEASES OP THE DIGESTIVE SYSTEM. 

been ingrafted upon some other pathological process in the intestines, as 
is not infrequent, there is found post-mortem evidence of this in the 
form of severe catarrhal inflammation, sometimes old ulcerations. In 
some cases, where the symptoms have been those of choleriform diarrhoea, 
there are found evidences of an intense diffuse gastro-enteritis, as shown 
by congestion of the stomach and almost the entire intestinal tract, with 
swelling of the mucous membrane, and especially of Peyer's patches. 

The microscopical appearances*— -Unless autopsies are made very soon 
after death — at least within four hours— it is not safe, in most of the cases, 
to draw conclusions from the conditions found; as post-mortem changes 
take place so readily in the intestines, and these changes are so like those ( 
of the disease under consideration. This applies particularly to the con- 
dition of the epithelium. One should also be cautious in interpreting the 
appearances of portions of the intestine which have been greatly distended 
with gas. The essential lesions of this disease are found in the superficial 
epithelium of the stomach and intestine. In places this has disappeared. 
In other places the cells are in position, but both the cell protoplasm and 
the nuclei are so changed that they do not stain normally. Bacteria, 
usually bacilli (Booker), are found in the epithelial layer and in the pockets 
of the follicles. They are not, as a rule, found in the deeper parts of the 
intestinal wall, nor in the lymph nodes of the mesentery. The changes 
in and about the blood-vessels are variable. The small vessels may be 
distended, and there may be haemorrhages or an exudation of leucocytes 
in their neighbourhood. These appearances are seen either in the mucous 
or submucous layer. The exudation from the blood-vessels is usually 
slight, and in many cases is wantiDg. Peyer's patches and the lymph nod- 
ules may be enlarged from cell-proliferation. Pathologically no sharp 
line can be drawn between these lesions and those of the early stage of 
ileo-colitis ; the latter affect the lower ileum and colon chiefly, often ex- 
clusively, and the lesions are more advanced and involve the deeper parts 
of the intestinal wall. 

Clinically, there are two quite distinct forms of gastro-enteric infection, 
which will be separately considered — (1) the simple form and (2) true 
cholera infantum. 

Simple (Castro-Enteric Infection. — There are seen in infants mild 
cases with a gradual onset, little or no fever, and no gastric disturbance, 
and severe cases with a sudden onset, usually attended by high tempera- 
ture and by vomiting. In the mild form, there may be for the first few 
days no symptoms except the diarrhceal discharges, or the children may 
be peevish and fretful — especially at night — and may seem generally out 
of sorts. From the fact that the general symptoms are so few, such cases 

* For fuller description, see article by the author in Keating's Cyclopaedia, vol. iii, 
p. 80. 



ACUTE GASTROENTERIC INFECTION. 321 

are often allowed to go on for several days, under the impression that the 
children are " only teething." The stools gradually become more frequent ; 
they are thin, green, yellow, or brown, and always contain undigested food. 
After a time the odour becomes offensive, and mucus is present. The ap- 
petite may be normal, but is usually impaired, and may be almost lost. 
The tongue is coated, the mucous membrane of the mouth congested, and 
in very young infants often covered with thrush. The general health may 
not be noticeably affected for several days ; but more often the infants 
become pale, their limbs grow soft and flabby, they lose their spirits, they 
are fretful, they sleep badly, and the scales show a loss of one or two 
pounds in a week. 

With proper treatment, there is noticed in favourable cases an im- 
provement in the character and frequency of the stools ; the appetite 
returns ; the strength and spirits improve ; and the children recover after 
an illness of from one to three weeks. Occasionally the condition may 
last a much longer time. Relapses are very easily brought on by errors 
in diet, especially by overfeeding. In other cases severe symptoms may 
supervene at any time, and the case may become one of the cholera-infan- 
tum type. This often takes place with great suddenness, and is frequently 
coincident with a few days of very hot weather, or follows some gross 
dietetic error. In still others the symptoms may continue with the grad- 
ual formation of follicular ulcers, the case becoming one of ileo-colitis. 
A termination, not so common as either of the preceding, is a continu- 
ance of the mild symptoms with exacerbations and remissions, until the 
cool weather of autumn comes. 

In the cases developing suddenly, the clinical picture is quite a differ- 
ent one. The attack may begin abruptly in a child previously healthy, 
or there may have been for some days a slight intestinal derangement. If 
an infant, it is restless, cries much, sleeps but a few minutes at a time, and 
seems in distress. The skin is hot and dry, the temperature rises rapidly 
to 102° or 103° F., often to 105°, and all the symptoms indicate the onset 
of some serious illness. The infant may lie in a dull stupor, with eyes 
sunken, weak pulse, and general relaxation, or there may be restlessness, 
excitement, even convulsions. There is great thirst, so that everything 
offered is eagerly taken, or everything may be refused. Usually, in the 
course of from four to six hours after the onset, vomiting begins ; it is 
first of undigested food taken many hours before. If this was milk, it 
comes up in hard curds and very sour. Even after the stomach has been 
apparently emptied, mucus, serum, and sometimes bilious matters, are 
ejected in small quantities after much retching. Vomiting is easily ex- 
cited by the giving of food or drink. 

Diarrhoea soon follows — first faecal stools, then great bursts of flatus, 
with the expulsion of a thin yellow material with an offensive odour. Four 
or five such discharges may occur in as many hours. In other cases the 
26 



322 DISEASES OF THE DIGESTIVE SYSTEM. 

stools are gray, green, or greenish-yellow, sometimes brown. They often 
do not differ at first from those of an ordinary attack of acute intestinal 
indigestion. The most characteristic features are the amount of the gas 
expelled, the colicky pains preceding the discharges, and the foul odour. 
After the first day the stools may be almost entirely fluid, varying in num- 
ber from six to twenty a day, and often large even then. Their offensive 
character usually continues. After two or three days mucus may appear.. 
The microscopical examination of the stools shows, besides the things 
mentioned in the stools of acute indigestion, great numbers of separate 
epithelial cells, and sometimes groups of cells attached to a basement 
membrane. In addition there may be round cells and some red blood- 
corpuscles. The bacteriological examination shows that the normal varie-^ 
ties are usually diminished in number, while many new forms are present, 
chiefly putrefactive bacteria. 

In many cases the free evacuation of the bowels is followed by a drop in 
the temperature and subsidence of the nervous symptoms, and the child 
may fall asleep, to be awakened for an occasional stool after a few hours. 
The prostration, though often great in the beginning, is not usually of 
long duration. Under the most favourable circumstances, after one or 
two days of severe symptoms, the case goes on to a rapid convalescence. 
The stools continue abnormally frequent for five or six days, but gradu- 
ally assume their normal character, and a prompt recovery occurs. The 
chief features contributing to such favourable results, are a good constitu- 
tion on the part of the child and one's ability to regulate the feeding after- 
ward. 

If the circumstances are not so favourable, if the infant is very young, 
delicate, or cachectic, there may be no reaction from the first storm of 
symptoms, and the attack may terminate fatally. In such cases the tem- 
perature continues elevated from 100° to 103° F., sometimes higher. The 
stomach is irritable and rejects everything. The stools continue thin, 
green, and are often irritating to the anus and skin. There is steadily 
increasing prostration, and death may take place from exhaustion in 
semi-stupor or in convulsions. In other cases the vomiting ceases, the 
temperature falls, the stools become less frequent and perhaps less offen- 
sive, but contain more mucus and occasionally traces of blood. There is 
also some reaction from the early nervous depression, but the children be- 
come pale, worn, and waste steadily. The temperature ranges between 99° 
and 102° F., and all the symptoms belonging to ileo-colitis gradually de- 
velop. Sometimes there may be a series of such acute attacks separated 
by a week or ten days, the stools never becoming quite normal between 
them, but all other symptoms being absent. It may not be until the 
third or fourth attack that ileo-colitis is finally established. 

In children over two years old there are seen some features which 
differ from the cases described above as occurring in infants. Vomiting 



ACUTE GASTRO-ENTERIC INFECTION. 323 

does not come on so readily as in infants, pain is a more prominent symp- 
tom, and the temperature, as a rule, is lower. Such cases, although be- 
ginning with severe symptoms, usually make good recoveries ; there is 
much less likelihood of their goiug on to the development of ileo-colitis 
than in the case of infants. 

Diagnosis. — The diagnostic points about these attacks are their sudden 
onset, severe symptoms, comparatively brief duration, and usually favour- 
able termination. Attacks of acute gastro-enteric infection can not always 
be 'distinguished from acute indigestion, but as a rule they are character- 
ized by a higher temperature, greater disturbance of the nervous system, 
very offensive fluid stools, and by occurring epidemically in summer. To 
differentiate these cases from those of ileo-colitis, may be impossible for 
the first two or three days. The onset may be identical in both cases. 
The continuance of high temperature beyond the second day points to in- 
flammatory changes ; so also does the appearance of blood and of much 
mucus in the stools, and the existence of continuous pain. 

Almost any acute disease in infants may be ushered in with gastro- 
enteric symptoms, especially in summer. This is particularly true of 
scarlet fever, pneumonia, tonsillitis, and malaria. Each one of these is to 
be recognised by its peculiar symptoms : pneumonia, by its rapid respira- 
tion and physical signs ; tonsillitis, by the appearance of the throat ; scar- 
let fever, by the appearance of the throat and the eruption ; malaria, by 
the enlarged spleen and remittent temperature. One should look for 
some other disease whenever there is seen very manifest improvement in 
the gastro-enteric symptoms, with a continuance of the high temperature 
and general prostration. 

Prognosis. — Simple cases of gastro-enteric infection do not often prove 
fatal, except in infants under three months old or those already suffering 
from marasmus. Such patients are often overcome in the first stage of 
intoxication. It is surprising to see with how few symptoms they suc- 
cumb. Even an apparently mild attack may prove fatal, and a guarded 
prognosis must always be given. 

In other cases the prognosis resolves itself into this question : What 
are the probabilities that the existing attack will go on to the develop- 
ment of serious intestinal lesions? If the child has been delicate, badly 
fed, has suffered from frequent attacks of indigestion and diarrhoea, if its 
surroundings are bad, if the case has been neglected for two or three 
days, and if proper dietetic and hygienic treatment can not be carried out, 
it is probable that the process will continue until structural changes in 
the intestine have taken place. The degree of probability is in propor- 
tion to the number of these factors present. Manifestly, all the condi- 
tions are worse in hot weather. Much depends upon early treatment 
and upon our ability to remove the exciting causes. If the patient was 
previously suffering from any other disease, such as rickets or ]3ertussis, 



324 DISEASES OF THE DIGESTIVE SYSTEM. 

the prognosis is much worse both as to life and to the duration of the 
attack. 

Prophylaxis. — So long as dentition and atmospheric heat per se were 
regarded as the great causative factors, the field of prophylaxis was limited ; 
but a better understanding of the etiology brings with it great possibili- 
ties in the prevention of this disease. 

Prophylaxis must have regard, first, to the hygienic surroundings of 
children, and to all sanitary conditions in the cities — cleaner streets and 
more parks. In the tenement homes and all institutions for infants, there 
should be more air and sunlight, less crowding, greater cleanliness about 
the persons of children, frequent bathing, and proper care of napkins. In 
summer, napkins should either be washed immediately or thrown into a 
disinfectant solution. In case infants are suffering from diarrhoea this 
latter plan should invariably be followed. City children should be sent to 
the country, wherever it is possible, for the months of July and August. 
Part of the benefit here is derived from the change of air, and a larger 
part from the pure milk, which is almost out of the question for the poor 
in the city. Where a long stay is impossible, day excursions do much good. 
The fresh-air funds and seaside homes have done more in New York to 
diminish the mortality from diarrhoeal diseases in summer than all medi- 
cinal treatment ; their importance and value can not be overestimated. 

The second part of prophylaxis relates to foods and feeding. Maternal 
nursing should be encouraged by every possible means. No weaning should 
be done, if it can be avoided, during summer. Nothing is better estab- 
lished than the close relation existing between artificial feeding and diar- 
rhoeal diseases. I have elsewhere stated my belief that in the great ma- 
jority of the cases it is ignorant and improper artificial feeding which is 
the real cause. The general rules laid down elsewhere on the subject of 
artificial feeding must be carried out, as to the quantity of food, fre- 
quency of feeding, modification of cow's milk, and all matters relating to 
the care, transportation, and sterilization of milk. "Whatever causes in- 
digestion, whether it be acute or chronic, may also be ranked as a cause 
of diarrhoeal diseases. The important dangers to be emphasized in this 
connection are overfeeding, too frequent feeding, the use of improper 
foods, and use of impure foods, especially milk. 

Overfeeding is particularly to be avoided during days of excessive heat. 
It is at such times an excellent rule with infants to diminish each meal 
by at least one third, making up the deficiency with water, and to give 
water very freely between the feedings. All water given to infants 
or young children should first be boiled. Children, like adults, require 
less food in very hot weather, but more water. Infants cry from thirst 
and heat, and even those at the breast are likely to be given too much 
food. Infants should never be fed more frequently during hot weather, 
but generally less so. 



ACUTE GASTRO-ENTERIC INFECTION. 325 

No greater work of philanthropy can be done among the poor in sum- 
mer, than to provide means whereby pure, clean milk for young children 
can be supplied at the price now paid for an inferior article.* 

Early and prompt attention should be given to all the milder derange- 
ments of the stomach and intestines. The larger proportion of serious 
attacks are preceded for some time by milder symptoms, which are often 
easily managed by prompt attention at the outset. Too much can not be 
said in condemnation of the practice of allowing a diarrhoea to continue 
for a week or more, simply because the child happens to be teething. Yet 
many mothers believe such a condition of the bowels to be, not only not 
injurious, but positively beneficial. 

In brief, prophylaxis demands (1) sending as many infants out of 
the city in summer as possible ; (2) the education of the laity up to the 
importance of regularity in feeding, the dangers of overfeeding, and as 
to what is a proper diet for infants just weaned ; (3) proper legal restric- 
tions regarding the transportation and sale of milk ; (4) the exclusion of 
germs or their destruction in all foods given, but especially in milk, by 
careful sterilization in summer, and by scrupulous cleanliness in bottles, 
nipples, etc. ; (5) prompt attention to all mild derangements; (6) cutting 
down the amount of food and increasing the amount of water during the 
days of excessive summer heat. 

Hygienic Treatment. — If the attack occurs in the city in midsummer, 
and does not yield in three or four days to the treatment employed, the 
child should be sent to the country, if possible. In the case of an infant 
under a year this is imperative. Usually the seashore is to be preferred 
to the mountains, but this is not so important as it is that the child shall 
go where it is likely to have the best food and the best surroundings. 
Children must not only be sent away ; they must be kept away until quite 
recovered. In the country or in small towns a change is not so necessary, 
and, in fact, not generally required. In cases which have become some- 
what chronic, more can sometimes be accomplished by a change of air 
than by all other means. 

Fresh air is of the utmost importance for all diarrhceal cases in sum- 
mer. No matter how r much fever or prostration there may be, these cases 
always do better if kept out of doors the greater part of the day. Nothing 
is so depressing as close, stifling apartments. Children should be kept 
quiet, and especially should not be allowed to walk, even if they are old 
enough and strong enough to do so. They can be kept out in carriages, 
in perambulators, or in hammocks. 

* Something of this has already been done in Boston by the milk laboratory, and 
in New York by the milk dispensary in connection with the Good Samaritan Dispen- 
sary, which has been organized by Koplik to furnish " sterilized " milk for infants ; and 
also by the Straus milk depots, where the same thing is done on a much larger scale, 
this charity having branches in half a dozen districts of the city. 



326 DISEASES OP THE DIGESTIVE SYSTEM. 

The clothing should be very light flannel ; a single loose garment is 
preferable. Linen or cotton may be put next the skin if this is very 
sensitive and there is much perspiration. At the seashore and in the 
mountains, special care should be taken that sufficient clothing at night 
is supplied. 

Bathing is useful to allay restlessness, as well as for cleanliness and the 
reduction of temperature. For the first purpose a sponge bath of alcohol 
and water or vinegar and water, is sufficient. For the reduction of tem- 
perature, only the tub bath is to be relied on. If the temperature con- 
tinues above 102° F., systematic bathing should be employed. The 
temperature of the bath should be about 100° F. when the child is put in- 
to it, and should then be gradually reduced to 80° or 85° F. by adding ice. 
The bath should be continued for from ten to thirty minutes, according 
to the requirements of the case. Thus used, it has generally a very quiet- 
ing effect, which is entirely lost by the terror and excitement caused by 
putting a young child suddenly into a cold bath. 

Scrupulous cleanliness should be secured in the child's person and 
clothing. Napkins, as soon as soiled, should be removed from the child 
and from the room and placed in a disinfectant solution. Excoriations of 
the buttocks and genitals are to be prevented by scrupulous cleanliness 
and the free use of some absorbent powder, such as starch and boric acid. 

Dietetic Treatment. — It is of the first importance to remember that 
during the early stage of the acute cases, digestion is practically arrested. 
To give food at this time, manifestly can only do harm. 

In nursing infants, the breast must be withheld so long as a disposition 
to vomit continues, and no food whatever given for at least twelve hours. 
Thirst may be allayed by giving frequently, but in small quantities, cold 
whey, barley or albumen water. Stimulants may be added to these if 
required. If they are refused or vomited, absolute rest to the stomach 
will do more than anything else to hasten recovery. After the stomach 
has been quiet for twenty-four hours, it is generally safe to allow the child 
to be put to the breast tentatively. The intervals of nursing should not 
be shorter than four hours, and the amount allowed at one feeding should 
not be more than one fourth the usual quantity. This may be regulated 
by allowing an infant to nurse at first only two or three minutes. Between 
the nursings may be alternated, whey, barley water, or albumen water, 
so that something is given every two hours. Nursing may be gradually 
increased, so that in three or four days the breast may be taken exclu- 
sively. If there is any reason to suspect the breast milk, such as menstru- 
ation, pregnancy, or some special nervous disturbance, it may be necessary 
to stop the nursing temporarily or permanently, according to circum- 
stances, and secure a wet-nurse or begin artificial feeding. In infants 
just weaned the same plan is to be followed. 

In infants under four months who are being artificially fed, if the 



ACUTE GASTRO-ENTERIC INFECTION. 327 

attack be a severe one and occur in summer, a wet-nurse should be se- 
cured wherever this is possible. If this is out of the question, we have 
to face one of the most difficult problems in artificial feeding. Cow's 
milk must always be withheld entirely during the stage of acute symp- 
toms, and for several days longer. When it is begun, both the casein and 
the fat must be very greatly reduced by dilution, and in many cases the 
casein predigested. For young infants, milk should be diluted from six 
to ten times, and preferably with a sugar solution. (See formulae XVII 
and XVIII, page 176). Instead of using only a sugar solution, part of 
the dilution may be with barley or rice water. In some cases it may be 
sufficient to peptonize milk for ten or twenty minutes ; but in many we 
must do more, at first continuing the peptonizing for two hours, or until 
the digestion of the casein is complete (page 148). Kumyss and matzoon 
are sometimes retained when cow's milk is rejected. These should be 
diluted with one or two parts of water and given cold. They may some- 
times advantageously be continued as the sole diet for several days. Dur- 
ing the period of acute symptoms we must rely upon the substitutes for 
milk — rice or barley water, wine whey, the malted foods, albumen water, 
fresh beef juice, animal broths, and the liquid beef peptonoids.* 

The same general principles of feeding must be applied in older chil- 
dren. All food is to be withheld until the vomiting ceases, and then 
broths and beef juice given ; later, kumyss or matzoon, then milk, or thin 
gruels made with milk. Solid food should not be allowed for several days 
after the stools have become normal. 

General p?*inciples of feeding. — All food, but especially cow's milk, 
must be stopped at once. No food whatever is to be given upon a very 
irritable stomach ; but thirst must always be relieved by bland fluids given 
frequently in small quantities, and cold. Articles requiring the least di- 
gestion and leaving the smallest residue should next be tried. Food pre- 
scriptions must be made with the. same care and exactness as those for 
drugs, for in most cases they are more important. Quantity and fre- 
quency must be definitely stated, as well as the articles ordered. Direc- 
tions should be given in writing, or they will be forgotten before the 
physician is out of the house. A practical acquaintance with the proper 
appearance and taste of every food ordered, is absolutely indispensable. 
It is a common mistake to give too much at a time, to feed too frequently, 
to try too many articles at once, and to change before a thing has been 
fairly tested. For a single feeding the quantity allowed will vary accord- 
ing to the tolerance of the stomach, but it should always be much less 
than is given in health, usually from one fourth to one half that amount. 
It is very rarely, if ever, necessary to nurse or feed a sick child oftener 
than every two hours. In cases of great prostration, stimulants may be 

* These foods are considered at length on pages 150-157. 



328 DISEASES OF THE DIGESTIVE SYSTEM. 

required much more frequently. We have only to imagine how an adult 
suffering from nausea would feel to be offered something in the shape of 
food every five or ten minutes, in order to appreciate the disgust for all 
food which soon overtakes an infant who is similarly besieged. 

Still, after all has been said, it is a difficult problem to feed these chil- 
dren under three years of age, capricious as they are by nature and still 
more by education, and the judgment and tact of the physician are taxed 
to their utmost. We must have many resources, for a food which one 
child takes well the next disdains utterly. The best plan is to select from 
a list of articles of accepted value, such as circumstances will permit, and 
such as are most likely to be properly prepared, and try them patiently, 
one after another, until one is found which the child under treatment 
will take, and one' which agrees with him. 

Medicinal and Mechanical Treatment. — It must be borne in mind that 
we are not treating an inflammation of the stomach or intestines, although 
such may be the ultimate result of the process. Our therapeutic meas- 
ures are to be directed against the acute indigestion and the active putre- 
faction in the alimentary tract. 

The first indication is, therefore, to evacuate the stomach and the en- 
tire intestinal tract at the earliest moment, and to do this as thoroughly 
as possible. Under no circumstances should the treatment be begun with 
the use of measures to stop the discharges. 

To empty the stomach is not necessary in every case, since the initial 
vomiting may have done this efficiently. Whenever vomiting persists 
immediate resort should be had to stomach-washing (page 60). A sin- 
gle washing is generally sufficient, and if employed at the outset may do 
much to shorten the attack. If there are high fever and great thirst, it is 
often advisable to leave an ounce or two of water in the stomach. If the 
vomited matters have been very sour, ten grains of bicarbonate of soda 
may be introduced with the portion which is to be left behind. To older 
children emetics may be given, but to infants never. As a substitute for 
stomach-washing in children over two years old, or where it can not be 
employed, copious draughts of boiled water may be given. This is taken 
readily, and as it is usually vomited almost at once it may cleanse the 
stomach thoroughly ; but it is inferior to stomach-washing. 

To clear out the small intestine, only cathartics are available. For the 
colon, we may in addition employ irrigation. Calomel and castor oil are 
greatly superior to all other cathartics. Calomel has the advantage of ease 
of administration, of a favourable effect upon vomiting, and of an anti- 
fermentative as well as purgative action. One fourth of a grain should 
be given every hour up to eight doses, or until the characteristic green 
stools are seen. When the stomach is not disturbed, I prefer castor oil in 
most cases, as it sweeps the whole canal, causes little griping, is very cer- 
tain, and its after-effects are soothing. It is important that a full dose be 



ACUTE GASTRO-ENTERIC INFECTION. 329 

given — two drachms to a child a year old, and half an ounce to one of 
four years. 

Irrigation of the colon (page G3) is advisable in all cases, as it hastens 
the effect of the cathartic and removes at once much irritating and offen- 
sive material. It should be done two or three times the first day, but 
afterward once daily is sufficient. A saline solution (one ounce to the 
gallon), at a temperature of about 80° F., is to be preferred ; and a long 
rectal tube should always be used. The initial evacuation, almost com- 
plete starvation for twenty-four hours, and careful feeding after that time, 
are all the treatment that is necessary in a large number of cases. 

Other drugs are of secondary importance. Their value is certainly 
very much overestimated. This statement is made after a thorough and 
honest trial, in hospital and private practice, of most of those that have 
been recommended. Since the recognition of the fact that putrefactive 
processes play so important a role in these cases, the drift of opinion and 
practice has been toward the use of drugs believed to act in the alimen- 
tary tract as antiseptics. In using drugs the conditions usually present 
are to be kept in mind : the digestive process in the stomach and upper 
small intestine is feebly carried on, and there is very active decomposi- 
tion in the lower part of the small intestine and in the colon. In com- 
parison with the intestinal contents, the amount of any drug which can 
be administered is so small, the conditions in the intestine are so com- 
plex, and our present knowledge of the exact nature of the processes of 
fermentation or decomposition w T hich we wish to control is so limited, 
that it is extremely doubtful whether such a thing as antiseptic medica- 
tion of the gastro-enteric tract is practicable at the present time. It is 
more than probable that a very large number of the drugs given to influ- 
ence this process, never reach that part of the intestine where the most 
active decomposition is going on. Experience has shown that certain 
drugs which have been classed as antiseptics are valuable, but as yet we 
must use them empirically. Those in my experience which have been 
found most useful are bismuth, calomel, salol, and salicylate of soda; 
although the list might be very much extended. 

Bismuth has the advantage that it rarely causes vomiting, and that 
most of its preparations can be given in large doses. Of the newer prepa- 
rations, the salicylate, subgallate and beta-naphthol bismuth, the subgallate 
is easily superior to the others. This may be given in doses of from two 
to four grains every two hours, to a child of one year. Like the subnitrate 
it is insoluble and is best given suspended in mucilage. The salicylate 
may be given in the same doses as the salicylate of soda. For the great 
majority of cases, however, I think the subnitrate is still to be preferred. 
To be efficient, at least two drachms of this should be given daily to a child 
one year old. It usually blackens the stools. It may be kept up through- 
out the attack. Calomel may be given in doses of one twentieth to one 



330 DISEASES OP THE DIGESTIVE SYSTEM. 

tenth grain every hour. Its best effects are seen where it is used early in 
the disease. It should not be continued for more than twenty-four or 
thirty-six hours. The gray powder may be given in the same manner. 
Salicylate of soda is probably decomposed in the stomach, setting free 
salicylic acid ; to a child of one year, two grains may be given, dissolved in 
water, every two hours, after feeding. This is not to be used if the stom- 
ach is very irritable, as it may excite vomiting. Its best effect is seen 
after the vomiting has stopped, and when the stools are fluid. It should 
be given alone. Salol is decomposed in the intestine into salicylic and 
carbolic acids. To a child of two years one grain may be given every two 
hours ; sometimes more will be borne. It may be given alone, or with bis- 
muth. This also may cause vomiting. Acids have been recommended, on 
the ground that the gastric contents, when examined, show a deficiency of 
hydrochloric acid, and from the experiments of Pfeiffer, which indicate that 
green stools are dependent upon an alkaline fermentation in the intestine. 
The acids most used are hydrochloric and lactic. Of the former, from 
one half to three drops of the dilute acid may be given, well diluted with 
water, every two hours, fifteen minutes after feeding. Of the latter, 
slightly larger doses may be used. They are not indicated in the most 
acute cases when vomiting is present, or when the stomach is easily dis- 
turbed. The best results are seen from them in the later stages and in 
the subacute cases. Acids are best given alone. Alkalies are of value 
only in acute cases, especially where there is acid fermentation of the 
stomach, with vomiting and eructations of gas. Limewater, bicarbonate 
of soda, magnesia, or chalk mixture may be employed. My own experi- 
ence accords with that of most recent writers in attributing to astringents 
little or no value. They often do positive harm, by disturbing the stom- 
ach and interfering with digestion. 

While opium in some form or quantity is required in many cases, as 
often used it undoubtedly does more harm than good. The chief symp- 
toms indicating opium are great frequency of movements and severe pain. 
It is contra-indicated until the intestinal tract has been thoroughly emp- 
tied by cathartics and by irrigation ; also when the number of discharges 
is small, particularly if they are very offensive; it is especially to be 
avoided when cerebral symptoms and high temperature coexist with 
scanty discharges. Opium is admissible in the early part of the disease 
after the tract has been thoroughly emptied ; it is also useful sometimes 
during convalescence, when the administration of food is followed imme- 
diately by a movement of the bowels ; and when, without an elevation of 
temperature, often with good appetite, the stools are frequent and contain 
undigested food, because peristalsis is so active that the intestinal con- 
tents are hurried along with such rapidity that there is not time for 
complete intestinal digestion and absorption. Nothing requires nicer dis- 
crimination than the use of opium in diarrhoea. It is wise to administer 



ACUTE GASTRO-ENTERIC INFECTION. 331 

it always in a separate prescription, and never in composite diarrhoeal 
mixtures. In this way it can be regulated according to the effect pro- 
duced upon the number of stools. If, following the administration of 
opium, the stools, though diminishing in number, do not improve in char- 
acter, and the temperature rises, the dose must be greatly reduced or the 
drug stopped altogether. There is no great choice as to preparations. 
Dover's powder, the deodorized tincture, and paregoric are perhaps the 
most satisfactory. As to dosage, great variations are required in the dif- 
ferent cases. Enough is to be given to produce a certain effect — the 
diminution of pain and the control of excessive peristalsis — but never 
enough to check the number of discharges entirely, or to cause stupor. 
The uncertainty of absorption must also be remembered ; a second full 
dose should not be given until a sufficient time has elapsed for the effect 
of the first to pass away. Better results are commonly obtained by the 
frequent use of very small doses, than by larger ones at longer intervals. 
For an average child of one year, five minims of paregoric, one fourth 
minim of the deodorized tincture, or one fourth grain of Dover's powder, 
may be used as an initial dose, to be repeated every one, two, or four 
hours, according to the effect produced. In some cases excellent results 
are obtained by the use of morphine hypodermically ; to a child of one 
year -^-q grain may be given, and the dose repeated in an hour if no 
effect is seen. 

Stimulants' are required in the majority of the severe cases. The pros- 
tration is great and develops rapidly ; frequently almost no food can be 
assimilated for twenty-four or thirty-six hours, while the drain from the 
discharges continues. The general condition of the patient is the best 
guide as to the time for stimulation and the amount given. Usually 
stimulants are not begun early enough. Old brandy is the best prepara- 
tion for general use, champagne possibly being preferred for older chil- 
dren when the stomach is very irritable. An infant a year old will, under 
most circumstances, take from half an ounce to an ounce of brandy in 
twenty-four hours. Stimulants should always be diluted with at least six 
parts of water, and should be given cold, preferably in small quantities, 
at short intervals. If they are not retained when given by the mouth, 
they may be used hypodermically. 

In cases of extreme prostration, the hot bath, mustard to the extremi- 
ties, and sometimes the mustard pack, are beneficial. Where the drain is 
rapid and very great, and in all cases approaching the cholera-infantum 
type, subcutaneous saline injections should be used, in the manner de- 
scribed under Cholera Infantum. 

General considerations in treatment. — (1) All severe cases must be 
watched very closely, especially those in infants under six months. If the 
temperature is rising and the passages are very fluid, one should always 
be apprehensive. (2) The character of the discharges is a better indica- 



332 DISEASES OF THE DIGESTIVE SYSTEM. 

tion than is their number, of the patient's condition and of the effect of any 
plan of treatment. (3) Nothing is more simple than to give opium enough 
to reduce the number of passages; but unless there is some other sign of 
improvement, very little good, and probably much harm, has been done. 
(4) We must treat the patient, and not direct all our thought to acid or 
alkaline stools, ptomaines, or bacteria. The value of every therapeutic 
measure is to be estimated by its effect upon the patient's general condi- 
tion. (5) No matter how strongly we may be convinced of the value of 
any drug or combination of drugs, if they continue to disturb the stom- 
ach they are worse than useless. (G) Both the mother and nurse must be 
impressed by the fact that the diet is an important part of the treatment, 
and that foods need to be given just as carefully as drugs. (7) In the 
management of any single case the important thing is prompt and thor- 
ough evacuation of the stomach and bowels, then rest for these organs 
for from twelve to twenty-four hours, or, as some one has tersely put it, 
" bold starvation " ; but it is necessary in all cases that water be given 
freely. No cases do worse than those in which the mother or nurse in 
charge can not be made to appreciate the value of starvation, but insists 
upon giving food, especially milk, in violation of the rules laid down. (8) 
Great care is required during convalescence, and in fact during the re- 
mainder of the summer, to prevent relapses ; these usually occur from 
errors in diet, particularly during days of excessive heat. 

Cholera Infantum. — In comparison with the class of cases just 
considered, cholera infantum is rare. The term should be restricted to 
cases of genuine choleriform diarrhoea. Much confusion has arisen from 
adopting this as a generic name for all cases of summer diarrhoea. There 
is no other form of diarrhoeal disease in which the evidence of infec- 
tious origin is so stroug. Its resemblance to Asiatic cholera is striking. 
Its close connection with the feeding of impure cow's milk is well estab- 
lished. The symptoms are essentially toxic, and are due to the effect of the 
poison upon the heart, the nerve-centres, and the vaso-motor nerves of the 
intestine. The secondary symptoms depend upon the abstraction of fluid. 

Cholera infantum may occur in an infant previously healthy, but this 
is very rare. As a rule, there is some antecedent intestinal disorder. It 
may be a mild diarrhoea of a few days' or even weeks' duration, or it may 
supervene in the course of a subacute ileo-colitis with such severity as to 
carry off the patient in a few hours. The development of the choleriform 
symptoms in all cases is very rapid, and a child, who perhaps has been 
regarded as scarcely ill enough to require a physician, may be brought, in 
the course of five or six hours, to death's door. 

Usually there are general symptoms — prostration, and a steadily rising 
temperature — for a few hours before the vomiting and purging begin, 
or these may be the first things to excite alarm. Vomiting may precede 
diarrhoea, or both may begin simultaneously. The vomiting is very fre- 



CHOLERA INFANTUM. 333 

quent. First, whatever food is in the stomach is vomited, then serum 
and mucus, and finally bilious matter. If it subsides for a time, it is 
almost sure to begin anew by the taking of food or drink. The stools 
are frequent, large, and fluid, and in the course of half a day, twelve 
or fifteen may occur. If less frequent they are proportionately larger. 
They are of a pale green, yellow, or brownish colour in the beginning, 
but as they become more frequent they often lose all colour and are 
almost entirely serous. The sphincter is sometimes so relaxed that small 
evacuations occur every few minutes. The first stools are usually acid, 
later they are neutral, and when serous they may be alkaline. In most 
cases they are odourless; in rare instances they are exceedingly offensive, 
at times the odour being overpowering. Microscopically the stools show 
large numbers of epithelial cells, some round cells, and immense numbers 
of bacteria. 

Loss of weight is more rapid than in any other pathological condition 
in childhood. Baginsky records a case in which it reached three pounds 
in two days. The fontanel is depressed, and in rare instances there may 
be overlapping of the cranial bones. The general prostration is great 
almost from the outset. The face, better, perhaps, than any single symp- 
tom, indicates what a profound impression has been made upon the sys- 
tem. The eyes are sunken, the features sharpened, the angles of the 
mouth drawn down, and a peculiar pallor with an expression of anxiety 
overspreads the whole countenance. In the early stages the nervous svmp- 
toms are those of irritation : children cry loudly or moan, and throw 
themselves fretfully about in their cribs, the excitement sometimes bor- 
dering upon an active delirium. Later, these symptoms give place to dul- 
ness, stupor, relaxation, and coma or convulsions. 

The temperature, in my experience, has been invariably elevated, and 
usually in proportion to the severity of the attack. In cases recovering, 
it has generally been from 102° to 103° F., while in fatal cases it has risen 
almost at once to 104° or 105° F., and often shortly before death it has 
reached 106° or even 108° F. Such a rectal temperature often occurs 
with a clammy skin and cold extremities, and is discovered only by the 
thermometer. Many writers speak of subnormal temperature in the later 
stages, but such has not been my experience. The pulse is always rapid, 
and very soon it becomes weak, often irregular, and finally almost imper- 
ceptible. The respiration is irregular and frequent, and may be stertorous. 
The tongue is generally coated, but soon becomes dry and red, and is often 
protruded. The abdomen is generally soft and sunken. There is almost 
insatiable thirst. Everything in the shape of fluids, especially ice-water, 
is drunk with avidity, even though vomited as soon as it is swallowed. 
Very little urine is passed, sometimes none at all for twenty-four hours ; 
yet this need give no special concern, as it depends upon the great loss of 
fluid by the bowels. 



334 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms such as those described rarely continue more than one day 
without a decided change either for better or worse. In the fatal cases 
there are hyperpyrexia, cold, clammy skin, absence of radial pulse, stu- 
por, coma or convulsions, and death. The diarrhoea and vomiting may 
continue until the end, or both may entirely cease for some hours 
before it occurs. The patients may pass into a condition resembling 
the algid stage of epidemic cholera, with pinched, sunken features, sub- 
normal temperature, dyspnoea, and cool breath, and may die in col- 
lapse. In other cases, after the first day of very severe symptoms, the dis- 
charges diminish, but the nervous symptoms become specially prominent. 
There are restlessness and irritability or apathy and stupor. The fontanel 
is sunken ; the eyes are half open and covered with a mucous film ; respi- 
ration is irregular and superficial, sometimes even Cheyne-Stokes ; the 
pulse is feeble, irregular, or intermittent ; the extremities are cold ; the 
muscles of the neck drawn back ; the abdomen retracted ; no desire for 
food is shown, the patient rousing only from thirst. The temperature is 
not elevated, but normal or subnormal. From this condition recovery may 
take place with gradual abatement of the nervous symptoms, improved 
pulse and circulation, the stools gradually becoming more consistent and 
having more colour ; or the symptoms may merge into those of ileo-colitis. 
Much more frequent than either of the foregoing, is the fatal termination. 

These nervous symptoms described were grouped by the earlier writers, 
first by Marshall Hall, under the term spurious hydrocephalus, or hy- 
drencephaloid. They have been variously explained by different writers 
as due to cerebral anaemia, cerebral hyperemia (venous), oedema of the 
meninges, thrombosis of the cerebral sinuses, and uraemia. In but a 
single instance have I met with post-mortem changes in the brain 
which bore any proper relation to the symptoms.* Although I have 
examined the brain in almost all my autopsies upon patients dying from 
diarrhoeal diseases, I have never in such cases seen sinus thrombosis, and 
but rarely oedema. Cerebral hyperemia was often met with in cases dying 
in convulsions, but not with any regularity otherwise. Nor have my obser- 
vations upon the kidneys confirmed the observations of Kjellberg, whom 
most of the writers since his day have quoted, as to the great frequency of 
nephritis. Albumen, casts and renal epithelium in the urine are rare, and 
blood I have never seen. The kidneys at autopsy are found generally 
paler than normal, with a moderate cloudy swelling of the cortex, but not 
more than in other febrile disorders of infancy. These facts forbid our 
regarding either the renal or the cerebral changes as an explanation of the 

* In this infant the cerebral symptoms were so marked and so characteristic that 
two excellent physicians who watched the case, unhesitatingly made a diagnosis of 
meningitis. The intestinal symptoms were considered of secondary importance. The 
autopsy revealed follicular ulcers of the ileum, moderate parenchymatous nephritis, 
and an extreme degree of cerebral anaemia. 



( I10LERA INFANTUM. 335 

nervous symptoms under consideration. With our present views of the 
pathology of cholera infantum, they are best regarded as toxic. 

In cases going on to recovery the vomiting usually ceases first ; then 
the stools become less frequent, contain more solid matter, and have more 
colour. Improvement in the pulse, a fall in the temperature, and subsi- 
dence of the nervous symptoms soon follow. The disappearance of the 
nervous symptoms is always to be regarded as a very favourable sign. The 
discharges gradually assume more and more of the character of a catarrhal 
diarrhoea, which continues a week or more. Convalescence is never very 
rapid. Sometimes, after all signs of improvement have continued for two 
or three days, the choleraic discharges return with great severity, and the 
case proves fatal. 

An infrequent complication of cholera infantum is sclerema. This 
condition is found associated with muscular contractions, subnormal tem- 
perature, and other signs of the most extreme depression. These cases 
are invariably fatal. 

Diagnosis. — Cholera infantum can scarcely be mistaken for any other 
form of intestinal disease if its chief symptoms are kept in mind — con- 
stant vomiting, profuse serous stools, great thirst, dry tongue, high tem- 
perature, and great restlessness, followed by rapidly developing collapse, 
sunken fontanel, pinched, anxious face, cold extremities, weak pulse, 
dyspnoea, cyanosis, stu}:>or, coma, and death. 

Prognosis. — The prognosis is worse in a very young infant, in one who 
has been badly fed and poorly cared for, when all the surroundings are 
unfavourable, when the patient has suffered from antecedent disease, and 
in midsummer. Yet fatal cases are often seen in infants previously 
healthy and living in good surroundings. There are cases in which it is 
evident, from the first few hours of the attack, that death will be the 
issue. The physician is never warranted in telling parents that the result 
would have been different had he been called in time. No matter 
what treatment is employed, the vast majority of the very severe cases 
terminate fatally. Of the cases of true cholera infantum which have come 
under my notice during the last ten years, fully two thirds have died. 
The result depends more upon the severity of the attack than upon any- 
thing else. 

Treatment. — Restricting the term to the class of cases described above, 
all who have seen much of the disease must admit that the results of 
treatment are extremely unsatisfactory, and that the most severe cases 
pursue their course but little, if at all, influenced by the treatment em- 
ployed. This statement is made after personal trial of almost every 
method of treatment which has been advocated by writers upon the subject. 

In the way of prophylaxis much can be done. All the general rules 
of prevention laid down in the previous chapter should be enforced here. 
Special emphasis, however, is to be laid upon the early treatment of the 



336 DISEASES OF THE DIGESTIVE SYSTEM. 

milder intestinal derangements, since it is a rule, to which the exceptions 
are few, that such symptoms precede for some days the occurrence of the 
choleriform diarrhoea. No case of diarrhoea in summer is to be neglected 
on the score of existing dentition. It is also important in convales- 
cence from ileo-colitis that vigilance should never be relaxed until the 
stools are normal. One frequently sees cases which, so far as it is pos- 
sible to judge, had been progressing steadily toward recovery, cut off in 
a day by the development of cholera infantum. 

The best view of the treatment will be gained if we keep in mind that 
we are not treating intestinal catarrh, nor intestinal inflammation, although 
this may ensue, but that these are essentially cases of poisoning ; that 
the toxic materials act by causing great depression of the heart and the 
system generally by acting on the nerve-centres, and by paralysis of the 
vaso-motor nerves of the intestines. 

The main indications are: (1) to empty the stomach and intestine ; 
(2) to neutralize the effect of the poison upon the heart and nervous sys- 
tem ; (3) to supply fluid to the blood to make up for the very great drain 
of the discharges ; (4) to reduce the temperature ; (5) to treat special 
symptoms as they arise. 

For the first indication we must rely upon mechanical means — stom- 
ach-washing and intestinal irrigation — for there is no time to wait for the 
action of cathartics. For the second, nothing in my hands has proved so 
useful as the hypodermic use of morphine and atropine. I believe this 
to be more efficient than any other means of treatment we possess. Mor- 
phine is contra-indicated where the purging has ceased or is slight, and 
where there is drowsiness, stupor, or relaxation. The effects of the dose 
should always be carefully watched ; a small dose repeated is better than 
a single large dose. For a child a year old, not more than gr. y^ of 
morphine and gr. -g-J^ of * atropine should be the initial dose. It may 
be repeated every hour until the desired effects are produced : these are, 
arrest of the vomiting and purging (or at least their diminution), improve- 
ment in the heart's action, and in the nervous symptoms. Here, as in 
shock, we find morphine our most reliable heart stimulant. The use of 
opium by the mouth is not to be relied upon, owing to the uncertainty of 
absorption and the liability to produce vomiting. 

For the third indication, it is useless to give fluids by the mouth. 
The only thing that can be depended upon is the injection into the cellu- 
lar tissue of a saline solution (common salt forty-five grains, sterilized 
water one pint). This may be injected into the cellular tissue of the ab- 
domen, buttocks, thighs, or back. To be efficient at least half a pint 
should be given in the course of every twelve hours. A very much 
larger quantity can often be used with advantage. This causes no irrita- 
tion, and is absorbed with surprising rapidity. A simple apparatus for 
making the injection has been devised by Dawbarn, viz., to attach the 



ACUTE ILEO-COLITIS. 337 

needle of a hypodermic syringe by a few inches of rubber tubing, to the 
nozzle of a bulb (Davidson's) syringe. It must be tied securely. Only a 
sterilized syringe should be used, and care must be taken to prevent the 
entrance of air. The injection is made slowly, and the exact amount 
introduced at each time, measured. 

Only baths are to be relied upon for the reduction of temperature. 
The graduated bath should be used, as described on page 48. It may 
be continued from ten to thirty minutes. To be efficient, it must be 
used frequently — as often as every hour if symptoms are threatening. Iced 
cloths or an ice cap should be applied to the head. Ice-water injections 
are a valuable accessory to the treatment by baths. A rectal tube should 
be used, and the injection carried high np into the colon, the water being 
allowed to flow in and out freely. Nothing should be allowed by the 
mouth except ice and iced champagne or brandy. The stimulants must 
be given in small quantities and frequently. When stimulants taken by 
the mouth are vomited, they should be given hypodermically. Brandy, 
ether, or camphor may be employed, and used freely. During the stage 
of most acute symptoms, to attempt to give food or drugs of any kind 
by the mouth is worse than useless. After the stage of violent symptoms 
has subsided and reaction is established, the subsequent management in 
respect to feeding and medication should be the same as in the cases con- 
sidered in the previous chapter. If the symptoms described as liydren- 
cephdloid are present, opium is to be avoided, stimulants by the mouth 
used freely, and, if these are not retained, they should be given hypo- 
dermically. For cold extremities and subnormal temperature, hot mus- 
tard baths should be used to establish reaction, mustard paste applied all 
over the body, and hot- water bags and bottles placed about the patient. 



CHAPTER VIII. 

DISEASES OF TEE INTESTINES.— {Continued.) 

ACUTE COLITIS AND ILEO-COLITIS. 

Synonyms: Enterocolitis, enteritis, enteritis follicularis, dysentery, inflammatory 
diarrhoea. 

The terms colitis and ileo-colitis are general ones, embracing those 
forms of intestinal disease in which there are found more serious le- 
sions than those of the superficial epithelium, which occur in acute .gas- 
troenteric infection. By separating these two groups of cases it is not 
meant to imply that cases of ileo-colitis are not infectious ; but in gastro- 
enteric infection recovery or death takes place before anything more than 
superficial changes have occurred, while in the ileo-colitis the pathological 
27 



338 DISEASES OP THE DIGESTIVE SYSTEM. 

process continues until there have been produced marked lesions, often 
involving all the walls of the intestine. Ileo-colitis is thus to be regarded 
as a condition in which any case of gastro-enteric infection may termi- 
nate. Sometimes the transition is so gradual that it is impossible, by 
symptoms, to draw a line between them. This is especially true of the 
cases terminating in follicular ulceration of the colon. In some of the 
other forms — acute catarrhal and acute membranous colitis — the evi- 
dences of a severe intestinal inflammation are often manifest from the 
very outset. This difference is probably due to the character of the infec- 
tion and its virulence in the two classes of cases. The extent of the le- 
sions depends very much upon the duration of the process. It has seemed 
wise, with our present understanding of these cases, to drop the term 
dysentery as a generic one, grouping them all under the general head of 
ileo-colitis until an etiological classification shall become possible. 

Etiology. — Most of the etiological factors discussed in the previous 
chapter apply with equal force to the cases of ileo-colitis. It may be sec- 
ondary to any of the infectious diseases, particularly measles, diphtheria, 
and broncho-pneumonia. Epidemics of ileo-colitis, in the true sense of 
the term, I have never seen. As to contagion, we are still in doubt as to 
the degree in which this is possible. Infants are most often affected, but 
the disease is not uncommon up to the fifth year. Attacks are more fre- 
quent in the summer, but they may occur at any season of the year. They 
are often seen in the fall months, when outbreaks sometimes seem to be 
very closely connected with marked changes in the temperature. 

But little is as yet definitely known regarding the nature of the infec- 
tion in cases of ileo-colitis. Booker found that the deeper lesions were 
almost invariably associated with the presence of streptococci, but whether 
they are primary or secondary is not easy to determine. What part the 
amoeba coli plays in the colitis of infancy and early childhood it is now 
impossible to say. Amoebae have been found by Oahen and others in the 
stools of typical cases, but thus far too few observations have been made 
to admit of any deductions. 

Lesions. — The nature of the lesions in ileo-colitis differs very much in 
the different groups of cases, but their position is quite constant : they 
affect the lower ileum and the colon. In about half the cases only the 
colon is affected. The lesions of the ileum are frequently limited to its 
lower two or three feet. 

The frequency with which the different varieties of ileo-colitis were 
found in eighty-two of my own autopsies was as follows : 

Follicular ulceration 36 

Catarrhal inflammation 26 

Catarrhal ulceration 6 

Membranous inflammation 14 

82 



ACUTE ILEO-COLITIS. 339 

Acute catarrhal ileo-colitis. — In the milder cases there are changes in 
the epithelium and infiltration of the mucosa. In the severe cases the 
submucosa is involved, and the infiltration of the mucosa may be so great 
as to lead to necrosis and the formation of catarrhal ulcers. 

Gross appearances : While the lower ileum and the colon are most 
seriously affected, it is not uncommon to find quite marked changes in a 
considerable portion of the small intestine, and even in the stomach. In 
the cases of short duration, the lesions are sometimes more marked in the 
small intestine than in the colon. The stomach contains undigested food, 
and mucus which is commonly stained a dark-brown colour. It may be 
dilated or contracted. The mucous membrane is pale or congested ; if 
the latter, it is usually in patches, and more about the pyloric orifice. 



fa 







m 



Fig. 52. — Acute catarrhal inflammation of the ileum. 

At the left is seen the edge of a Peyer's patch (P) greatly swollen. The most striking 
feature of the lesion is the loss of the superficial epithelium, which is shown in all parts of the 
specimen. The significance of this depends upon the fact that the autopsy was made but two 
hours after death. ~ At several points. i\ F, the tubular follicles have loosened and fallen out. 
The mucosa, A, is slightly infiltrated with cells, especially near the Peyer's patch. The sub- 
mucosa, C, and muscular coats, D, E, are normal. I , F, are small veins. * History. — Infant, nine 
months old, previously healthy ; sick three days with severe intestinal symptoms ; temperature. 
103° to 105° F. Autopsy. — Acute catarrhal inflammation of ileum and colon: Peyer's patches 
red and swollen. The specimen is taken from the lower ileum. The superficial character of 
the lesion is chiefly due to the short duration of the process. 

The intestinal contents are generally green in colour, and thin. The 
mucous membrane is often coated with tenacious mucus. The small in- 
testine is distended with gas, the large intestine nearly empty, except the 
transverse colon. The mucous membrane may appear somewhat swollen. 
In the small intestine there are occasionally seen swelling and oedema of 
the villi, so that they project abnormally and give a plush-like appearance. 
Congestion is a constant feature, and it may be simply upon the folds of the 
mucous membrane, or about the solitary lymph nodules ; or it may be in- 
tense and involve the whole intestine for some distance. Small hemorrhagic 
areas are often seen here and there, widely scattered. In the most severe 
cases there are marked thickening and uniform congestion, and the appear- 
ance is sometimes much like that seen in membranous inflammation. The 



340 



DISEASES OF THE DIGESTIVE SYSTEM. 



lymph nodules (solitary follicles) throughout the colon are usually swollen, 
projecting above the mucous membrane about the size of a pin's head. 
Peyer's patches may be normal, or they may be swollen and congested, 
with other evidences of catarrhal inflammation in the surrounding mucous 
membrane, or more rarely they may be involved when the rest of the mu- 
cosa appears healthy. The same is true of the lymph nodules of the small 
intestine. The lymph nodes of the mesentery are usually swollen and 
acutely congested, but they may appear normal. 

Microscopical appearances : In interpreting the changes found in the 
mucosa, the same precautions must be observed as stated on page 320. 

There is usually loss of the superficial epithelium and of that lining 
the tubular glands at their orifices. Upon the surface of the mucosa and 











Fig. 53. — Acute catarrhal inflammation of the ileum ; severe form. 

The mucosa, (7, is everywhere densely infiltrated with round cells, compressing the tuhular 
follicles, and in places, Z, Z, almost effacing them. Upon the surface of the mucosa is a thick 
layer of cells and mucus. Beneath this tfie epithelial arches, Z, Z, covering the villi can be 
seen. The lesions are almost entirely of the mucosa. The only changes in the submucosa, Z 7 , 
are groups of cells about the small blood-vessels, V, V. History. — Infant six months old ; mod- 
erate diarrhoea twelve days; severe symptoms with high temperature for six days. There was 
intense inflammation of the entire colon and lower three feet of the ileum. Intestine greatly 
congested and thickened. Specimen is from the ileum. 

within the tubular glands, fine granular matter is seen from the broken- 
down epithelium. The goblet cells are distended with mucus, and do 
not stain clearly. The lumen of the tubular glands is narrowed from 
pressure due to the swelling of the lymphoid tissue which separates them, 
which is partly from oedema, and partly from cell infiltration (Fig. 52). 
Entire tubular glands may loosen and fall out. A thick layer of mucus 
and round cells, adhering closely to the surface, may resemble pseudo- 
membrane (Fig. 53). In the milder varieties the infiltration with round 
cells is not great and is usually limited to the mucosa, the extent depend- 
ing principally upon the duration of the process. In the very severe cases 



PLATE VIII. 











~>„. VW^G ^ \ ^ ■ v • 




- : £S 
I 

I 


1 


, 




-,;,;:■ c/^. .^4 


1 ' 


A^ 


. "4 1 iH 

1 \ 

► --*eL^ 




.■■ : ■ 


R 


w* 






D 


■&,\ij$3" 




._„_, - ^' ' T \w^>- ^ ' 












D _ 




'&LA &,. f . » ^ 




D 


... . 

\ 


■77- • jp^^fc/^ " -* - * -*^ h 4'-" • y 






B 
C 




C 






■ ** r" 


■>* '' # *?; 






--"V 








*> 


WKrW-mm Jdf, . .jdm^.* 





Extensive Catarrhal Ulceration of the Colon. 

Female child nine months old ; symptoms of acute ileo-colitis of fifteen days' dura- 
tion; temperature, 101° to 104*5° F., and from six to eight stools daily — thin, green, 
and yellow, but no blood. 

Extensive ulceration throughout the colon, most marked in descending portion, 
from which specimen is taken. 

A A are small circular ulcers ; B B, larger ones from coalescence of several of 
these ; C C, large areas of ulceration, the mucous membrane being almost entirely 
destroyed. 



ACUTE ILEO-COLITIS. 341 

there is found a dense infiltration of the mucosa and of the submucosa 
also, which in places extends quite to the muscular coat. These cases 
closely resemble those of the membranous variety, lacking only the exuda- 
tion of fibrin. The lymph nodules o£ the colon are swollen to a greater 
or less degree, chiefly from an increase in the number of lymphoid cells. 
This swelling may be the most prominent feature of the lesion. If the 
process is sufficiently prolonged, the lymph nodules may break down and 
ulcerate. The changes in the lymph nodules of the small intestine and 
in Peyer's patches are similar to those seen in the colon, but are less 
marked, and frequently absent altogether. Ulceration in Peyer's patches 
is extremely rare. 

The small veins and capillaries of the submucosa and mucosa are 
usually distended with blood ; small extravasations are very common, and 
occasionally larger ones are seen. 

Catarrhal inflammation, except in its very severe form, which is not 
frequent, causes no lesions that can not readily be repaired. The most 
persistent change is usually the swelling of the lymph nodules, which may 
last a long time, and appears to be an important factor in the tendency to 
relapses and recurring attacks. If there is a continuance of the exciting 
cause, or the patient's constitution is a bad one, the process may become 
chronic. 

Catarrhal ulceration. — In the most severe form of catarrhal inflam- 
mation which does not prove fatal in the earlier stages, extensive ulcer- 
ation occasionally takes place ; usually these ulcers are seen throughout 
the entire colon, and, in rare cases, a few are found in the lower ileum. 
They generally begin in the mucosa overlying the lymph nodules, and 
while they have a. wide superficial area, they do not extend deeper than 
the mucosa. The small ulcers are circular and usually show at the centre 
a small granular body — the lymph nodule. The larger ulcers result from 
the coalescence of several small ones, and are irregular in shape. They 
may be two or three inches in diameter. Sometimes for a considerable 
distance a large part of the mucosa may be destroyed. Often the en- 
tire surface presents a worm-eaten appearance (Plate VIII). On micro- 
scopical examination there is seen, in the greater part of the ulcer, com- 
plete destruction of the mucosa; the submucosa being- densely packed 
with round cells quite to the muscular coat. 

Inflammation of the lymph nodules with ulceration (follicular ulcera- 
tion). — Follicular ulcers are found at autopsy in about one third of the 
cases dying from diarrhceal diseases. They are rarely seen in those which 
have lasted less than a week, and not often before the middle of the 
second week ; the average duration of the cases being about two and a 
half weeks. 

In thirty-six cases in which follicular ulcers were found at autopsy, 
they were present in the small intestine alone in but three cases ; in the 



342 



DISEASES OF THE DIGESTIVE SYSTEM. 



small intestine and in the colon in six cases ; in the remaining twenty- 
seven they were present only in the colon. When in the small intestine 
they were seen only in the lower ileum. Ulceration was seen a few times 
in one or two of the nodules of a Peyer's patch. Ulceration of the large 
intestine involved the whole colon in about half the cases ; while in the 
remainder the process was limited to its lower portion. The deepest and 
also the largest ulcers were usually in the descending colon and sigmoid 
flexure. 

In the early stage these ulcers appear as tiny excavations at the summit 
of the prominent lymph nodules. Later, the whole nodule may be de- 
stroyed, and a small round ulcer is formed from one twelfth to one fourth 
of an inch in diameter (Plate IX). These are quite deep and have over- 
hanging edges ; when closely set they give the intestine a sieve-like ap- 







Fig. 54.— Lymph nodule of the colon in the early stage of ulceration — Follicular ulcer. 

The nodule, F, is much enlarged, and is breaking down and discharging into the intestine. 
The other changes are not marked. The superficial "epithelium is gone- the mucosa, A, shows 
a slight increase of cells, and in the submucosa, O. are nests of cells about the small vessels, F, V. 
History. — Delicate child, thirteen months old ; slight diarrhoea four weeks ; severe symptoms 
five days. The colon was filled with ulcers one twelfth of an inch in diameter, one of which 
is shown in the illustration. 

pearance. By the coalescence of several of them, larger ulcers may form 
which are an inch or more in diameter. At the bottom of these larger 
ones the transverse striae of the circular muscular coat are often plainly 
seen. I have never known them to cause perforation. 

Microscopical appearances : The lymph nodules are swollen, principally 
from the accumulation within them of round cells. This is followed by 
softening, which usually begins at the summit of the nodule and ex- 



PLATE IX. 



mm mmmm Mmmm : ~ ' ■ ~ 



• - E 



^ * 



Deep Follicular Ulcers of 



the Colon. 

stools green, yellow, brown, 



A delicate child, fourteen months old, sick twelve days 
and watery; no blood ; temperature, 100° to 101° F. 

The small intestine was normal ; ulcers throughout colon. The specimen is from 
descending colon; the ulcers are deep, and most of them extend to the muscular coat. 
(For microscopical appearance, see Fig. 55.) 



ACUTE ILEO-COLITIS. 343 

tends downward ; the reticulum breaks down, and the cellular contents 
escape into the intestine (Fig. 54). Softening may begin at the centre 
of the nodule, which ruptures like an abscess. The destruction of the 
whole nodule leaves a cavity, which is the follicular ulcer. At first the 
ulcers correspond in size to the nodule, but meanwhile infiltration of the 
adjacent tissue has taken place, and this may become necrotic. In this 
way the ulcer extends, chiefly in the submucous coat. The lesion is never 















Fig. 55. — Deep follicular ulcer of the colon. 

A deep ulcer is shown at F, a smaller one at F'. The separation of the mucosa at ZHs acci- 
dental. There is no trace of the lymph nodule from which the large ulcer had its origin. The 
destructive process has extended laterally in the submucosa, C, and the mucosa, A, is falling in 
to fill up the space. In the vicinity of the ulcers, the submucosa is densely infiltrated with 
round cells, Z", Z", which also are seen in the lymph spaces between the bundles of circular 
muscular fibres, Z', Z', and some are seen in the longitudinal muscular coat, Z, Z. History. — 
Thirteen months old, delicate ; continuous diarrhoeal symptoms for three weeks. Ulcers found 
throughout the colon, the largest, one half an inch in diameter. The illustration shows one of 
the small ones like those in Plate IX. 

limited to the lymph nodules ; but the extent of the other changes found, 
depends upon the severity and the duration of the process. In cases 
dying after an illness of a week or ten days, we usually find only moderate 
changes in the mucosa, and in the submucosa a slight infiltration of round 
cells, especially about the small blood-vessels (Fig. 54, V, V). In those 
which have lasted three or four weeks the ulcers are deeper, and all the 
structures of the intestine in their neighbourhood, are usually involved 
(Fig. 55). The mucosa is densely packed with round cells, as are also 
all the tissues in the vicinity of the ulcers ; even the muscular coat may 
be infiltrated. The ulcers, however, rarely extend deeper than the circu- 
lar layer. 

Follicular ulceration of the intestine in infancy, usually terminates 
fatally if the process is an extensive one. In less severe cases, recovery 
may take place, the ulcers healing by granulation and cicatrization in the 
course of from four to eight weeks. 

Acute membranous ileo-colitis. — This is the most severe form of intes- 



344: DISEASES OF THE DIGESTIVE SYSTEM. 

tinal inflammation seen among children. The process differs quite mate- 
rially from that described as occurring among adults. In only one of my 
own cases was it associated with membranous inflammation of any other 
mucous membrane, in that case with membranous gastritis. A speci- 
men was presented to the New York Pathological Society in 1889 by Sel- 
lew, in which this lesion was associated with pseudo-membranous inflam- 
mation of the pharynx. Membranous colitis usually runs a short, intense 
course, with a temperature which continues moderately high, severe 
constitutional symptoms, and death generally in eight or ten days. The 
shortest case I have seen lasted six days. If recovery takes place it is only 
after a very prolonged illness. 

Gross appearances : There is visible to the naked eye usually very little 
pseudo-membrane and no deep sloughing. The lesion affects with remark- 
able uniformity the last two or three feet of the ileum and the entire colon. 
It is exceedingly rare to meet with any marked lesions high in the small 
intestine. The most marked changes are near the ileo-caecal valve or in 
the sigmoid flexure and the rectum. In the ileum they are usually quite 
as severe as in the colon (Plate X). The intestinal wall is firm and stiff, 
and is two or three times its normal thickness. It is not thrown into deep 
folds, as is the healthy intestine when empty. It is very rare to find false 
membrane that can be stripped off in patches of any considerable size. 
Where membrane exists, the colour is a grayish green, and the surface is 
often fissured, giving a lobulated appearance. In the parts where no 
pseudo-membrane can be seen, the surface is usually of an intense red 
colour and is rough arid granular, in striking contrast to the normal glist- 
ening appearance. Here and there small extravasations of blood may be 
seen. In the regions most affected, the normal structures of the mucous 
membrane — the villi, Peyer's patches, and solitary follicles — can not be dis- 
tinguished. Although the whole colon is diseased, the lesions differ very 
much in severity in the different regions, and large areas of pseudo-mem- 
brane are rare. In a single instance I found an exudation of fibrin on the 
peritoneal surface of the intestine for a short distance. Except in the 
lower ileum the small intestine shows no constant changes, and none are 
usually found in the stomach. 

Microscopical changes : These (Fig. 56) are much more uniform than 
the gross appearances. The most characteristic feature is the exudation 
of fibrin, which forms a distinct pseudo-membrane upon the surface of the 
intestine, and may infiltrate the mucosa, and even the submucosa. Fibrin 
is found under the microscope in parts of the specimen, which to the 
naked eye shows no distinct pseudo-membrane, but only a granular ap- 
pearance. In rare cases a fibrinous exudation may be found upon the 
peritoneal covering of the intestine. The pseudo-membrane is made up 
of a fibrinous network containing small round cells, some red blood-cells, 
and bacteria, chiefly cocci. The mucosa, and usually the submucosa, are 



PLATE X. 




Membranous Inflammation of the Ileum. 

A delicate child, eleven months old; mild diarrhoea for two weeks without fever; 
severe symptoms for twelve days; temperature, 100° 



to 102-5' P. ; green and 



acute 

mucous stools : no blood. 

The lesions involved the last foot of ileum and entire colon. Specimen is from 
lower ileum, and shows the abrupt termination of the lesion; the upper pari shows 
normal small intestine; A is a Peyer's patch ; B is the inflamed part of the intestine ; 
it has a rough granular appearance and is much thickened. 



ACUTE ILEO-COLITTS. 345 

densely infiltrated with small round cells, which in places may be so nu- 
merous as to efface the normal elements of the intestine. The tubular 
follicles are in some places quite destroyed, not a vestige of them remain- 
ing. In other places they are compressed and distorted by the accumula- 
tion of cells! The great thickening of the intestine is due partly to the 
cell infiltration, partly to the fibrinous exudation, and partly to oedema. 
All the blood-vessels, both in the mucosa and submucosa, are gorged 




^ 






Fig. 56. — Membranous inflammation of the colon. 

The intestine is covered with a pseudo-membrane, J/", which is composed chiefly of granu- 
lar fibrin; the mucosa. A, is densely packed with round cells, and the tubular follicles have 
almost disappeared, traces only being left at T 7 , T. The submucosa, C, is greatly thickened, 
partly from cells, but chiefly from fibrin, which with a high power is seen to be everywhere in 
this coat, as well as the mucosa. Nests of celis are seen in the muscular coats at L. L. ' At F is a 
lymph nodule covered by pseudo-membrane, but breaking down at its centre. J\ V. are small 
blood-vessels with nests of cells about them. History. — Fourteen months old; ill nine days; 
temperature 101° to 105° F. ; all stools containing blood. Lesions found throughout colon and 
in lower ileum. Intestine greatly thickened. Specimen is from ascending colon, where lesion 
was especially severe. 

with blood, and many small extravasations are seen. A necrotic process 
with the formation of deep ulcers I have never seen associated with mem- 
branous colitis. 

Associated lesions of ileo-coHtis. — The most important one is broncho- 
pneumonia, It is found in quite a large proportion of the protracted 
cases, and not infrequently it is the cause of death. I have once sei 
pulmonary abscess complicating ulcerative colitis. It was at the apex, 
and was not associated with abscesses elsewhere in the body. Bronchitis 
is a very common complication. Peritonitis is rare, and when present is 
usually circumscribed and of the plastic variety. Acute degeneration of 
the epithelium of the kidney (cloudy swelling) is fairly common, and in 



346 DISEASES OF THE DIGESTIVE SYSTEM. 

fact it is usually found in the cases which have been marked by high tem- 
perature. Exudative nephritis is, however, in my experience very rare. 
There are no characteristic or uniform changes found either in the liver, 
spleen, heart, or brain. 

Symptoms. — (1) Catarrhal cases of moderate severity. — The onset is 
usually sudden, often with vomiting, and for twelve, sometimes twenty-four, 
hours the symptoms may be those of acute indigestion : vomiting, pain, 
fever, and frequent thin green or yellow stools, which are partly faecal and 
contain undigested food. Later the characteristic discharges are seen. 
These are composed of blood and mucus ; they are preceded by pain and 
usually accompanied with tenesmus. The stools are very frequent, often 
every half hour and proportionately small, sometimes less than a table- 
spoonful being found upon' the napkin after severe straining efforts. The 
mucus may be clear and jelly-like, or it may be mixed with faecal matter. 
Blood is seen in almost every stool, but rarely in clots, usually streaking 
the mucus. Fluid blood may be present. These stools are almost odour- 
less. After two or three days the blood usually disappears, or is seen only 
as traces in an occasional stool. Mucus is still present in large quantities, 
making up the bulk of the stool. The colour of the discharges now be- 
comes a dark brown or a brownish-green. Prolapsus ani is frequent, and 
often occurs with nearly every -stool. For the first twenty-four hours the 
temperature is usually high, from 102° to 104° F. Later, and throughout 
most of the attack, it ranges from 99° to 102° F. In the mildest cases it 
may not be above 101° F. at any time. The prostration is not so great at 
the outset as in most forms of intestinal disease, but increases steadily for 
several days. The appetite is lost for the first two or three days, but there is 
usually great thirst. Abdominal pain is present and is often quite intense 
just before the stool. In most cases there is tenderness along the colon. 

The duration of the severe symptoms is usually less than a week, and 
even though the child was previously in good condition and properly 
treated, recovery is rarely rapid. The first symptom of improvement is 
generally the disappearance of blood from the stools, which at the same 
time become less frequent, and the pain and tenesmus cease. Gradually 
the stools assume more of a faecal character, but mucus is likely to persist 
for two or three weeks ; it may be seen in all stools, or only occasionally. 
In some cases both the mucus and blood disappear and the stools become 
thin, brown, or green, like those of an ordinary diarrhoea. Although 
the early stage of very acute symptoms may last but a few days, if there 
is a continuance for two or three weeks of the brown, mucous stools, with 
emaciation and slight fever, ulceration is probably present. This is likely 
to occur if the child is in poor condition, if its surroundings are bad, 
or if it is improperly treated at the outset. Eelapses are readily excited, 
but cases like the above are rarely fatal except in very delicate infants. 
This is the most common form of ileo-colitis which terminates in recovery. 



ACUTE ILEO-COLITIS. 347 

(2) The severe catarrhal form. — The symptoms closely resemble those 
of the membranous variety, and a diagnosis from it is to be made only by 
the absence of pseudo-membrane from the stools. The most rapid case I 
have seen lasted but three days, but the usual duration is from one to two 
weeks. The temperature is steadily high ; the stools continue very fre- 
quent and contain much blood ; there are great prostration, dry tongue, 
sordes on the lips and teeth, and prominent nervous symptoms. Death 
usually occurs from exhaustion and profound sepsis while the acute symp- 
toms are at their height. If the patient survives this stage, the case may 
drag on for four or five weeks, very much like the one of follicular 
ulceration, and then terminate in recovery or in death from slow as- 
thenia, broncho-pneumonia, or an acute exacerbation of the intestinal 
symptoms. The autopsy in such cases usually reveals the presence of ca- 
tarrhal ulcers. If recovery is to be the outcome, after the symptoms have 
been nearly stationary for a long time, there is seen a gradual turn for 
the better, and improvement first in the general and then in the local con- 
ditions. Convalescence is very slow, often interrupted by relapses, and it 
may be months before the patient is quite well. In some cases the child 
never regains its former vigour. 

(3) Follicular ulceration : ulcerative inflammation of the lymph nod- 
ules. — Follicular ulceration is not very often met with in infants under six 
months of age. Of thirty-six cases in which the diagnosis was confirmed 
by autopsy, all but four were between the ages of six and twenty-one 
months. The great majority of these children were in poor condition at 
the time of the attack. 

To understand the symptoms of these cases, it must be remembered 
that follicular ulceration is the terminal process to which continued cases 
of acute gastro-enteric infection tend. It may be preceded by one or 
more acute attacks, or by a protracted subacute attack. On account of 
the feeble resistance of the child or the continuance of the exciting cause, 
the pathological process gradually extends from the epithelium to the 
lymph nodules of the intestine, chiefly the colon, which, as already de- 
scribed, pass successively through the stages of swelling, softening, and 
ulceration. The onset of the illness may therefore be sudden, with vom- 
iting and high fever; or gradual, without vomiting and with very little 
fever. The patient may be ill for a week before the exact type which the 
disease is assuming can be positively determined. It is not possible to 
mark the transition from acute gastro-enteric infection to follicular ileo- 
colitis. Usually the latter may be assumed to exist whenever, after one of 
these attacks, there is a continued temperature above 101° P., and when 
the stools habitually contain large quantities of mucus without blood. 

Vomiting is not a feature of these cases ; but it is often presenl ;it the 
onset. Throughout the attack it is easily excited by injudicious feeding 
or medication. The temperature is seldom high, except at the onset; 



348 



DISEASES OF THE DIGESTIVE SYSTEM. 



its usual range is from 99° to 101° F. ; toward the close, even of fatal 
cases, it may be scarcely above the normal. The accompanying chart (Fig. 
57) is a very good illustration of the course of the temperature in cases 
beginning abruptly and ending fatally. 

The stools are not usually very frequent, the number being from four 
to eight a day. The most constant feature is the presence of mucus, 
which is mixed with the stools and usually abundant. Blood is not gen- 
erally present, and a large amount of blood is extremely rare. It was ab- 



DAY 




1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


26 


27 


28 


29 


30 


31 


32 


33 


34 


DATE 


OCT. 


16 


17 


IS 


19 


20 


21 


22 


23 


24 


25 


26 


27 


23 


29 


30 




iov 

i 


■2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


16 


17 


18 


H 
u] 

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z 
111 

I 
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u 

uT 
tr 

D 
H 
< 

a 
in 

a 

tu 

H 

ST 


106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 
OOLS 


"' 


«. E 
































































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l\ 


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J 




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A 
















































V 


U 


r 


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V 


V 


\t 




P 


/ 


s 


, 


/\ 






, / 
















































\ 


1 


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s 


/ 


\ / 


N 








u 














































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\i 




































































V 




















































































7 


6 


6 


3 


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2 


3 


5 


4 


5 


4 


5 


5 


5 


2 


3 


3 


3 


5 


5 


4 


4 


6 


4 


6 


4 


4 


2 


5 


5 


3 


5 


5 


z 



Fig. 57. — Temperature chart of ileocolitis, fatal on thirty -fourth day. Autopsy showed follicu- 
lar ulcers throughout the colon. 



sent entirely in more than half of my cases in which the diagnosis was 
confirmed by autopsy. A small quantity of blood early in the attack is 
not uncommon, depending here upon congestion. Large haemorrhages 
from ulcers I have never seen. The colour of the stools is most fre- 
quently of a dark green or brown. Fluid stools are seen only during ex- 
acerbations. The odour is usually offensive, particularly in protracted 
cases. The microscope shows epithelial cells in great numbers, and very 
often an abundance of small round cells, which may be looked upon as the 
most constant sign of ulceration. 

The failure in nutrition and steady loss in weight are very constant in 
these cases. As emaciation goes on, the skin hangs in loose folds on the 
thighs ; it becomes dry and scaly and loses its elasticity, and occasionally 
small petechial spots are seen upon the abdomen. The skin over the but- 
tocks becomes excoriated, and bed-sores form over the heels, the sacrum, 
or the occiput. The abdomen may be moderately distended, or it may be 
relaxed and soft. Tenderness is not usually present. The appetite is lost, 
and in most cases great difficulty is experienced in getting children to 
take a proper amount of nourishment. Continued aversion to food is an 
unfavourable symptom. Occasionally, when there is fever, fluids are 
taken eagerly. A returning appetite is always an encouraging sign. 
The mouth is often dry, the tongue coated, sometimes dry and brown ; 
there may be sordes upon the lips and teeth. Superficial ulcers form 
upon the mucous membrane of the mouth, and often thrush is seen. The 



ACUTE ILEO-COLITIS. 



349 



urine is usually diminished, high-coloured, and loaded with urates. Al- 
bumen and casts are rarely present. In only one case have I seen ne- 
phritis severe enough to form a factor in the result. Tenesmus and pro- 
lapsus ani are uncommon. 

The average duration of the fatal cases is about three weeks ; their 
course is often marked by exacerbations and remissions. If recovery takes 
place, convalescence is always very slow and relapses are easily excited. 

Very few of these cases recover completely. Even those who survive 
the primary illness are likely to suffer from intestinal symptoms for many 
months. Fatal relapses are often brought on by injudicious feeding when 
the children are apparently almost well. The general health is usually so 
undermined that the patients continue to suffer from all the symptoms of 
malnutrition, and ultimately succumb to an attack of some intercurrent 
acute disease. 

The diagnosis of ulceration is to be made from the case as a whole 
rather than from any special symptoms. If a delicate infant which has 
previously been prone to diarrhceal attacks, has green nlucous stools with 
low fever, and these continue with unabated severity for ten or twelve 
days, ulceration is probable. If such symptoms continue for three or four 
weeks with steadily failing strength and loss of weight, the diagnosis is 
almost certain. If, on the contrary, after three or four days of acute 
symptoms there is improvement in the stools and occasionally some which 
are quite faecal in character, even though it may be a week or more before 
the mucus disappears, we may be quite certain that no ulcers have formed. 

(4) The membranous form. — This 
occurs most frequently between the 
ages of six months and two years, and 
often attacks those previously in good 
health. It is the gravest form of in- 
flammation of the intestine seen in 
children, and its symptoms are severe 
usually from the outset. It closely 
resembles the most severe cases of 
catarrhal inflammation. The disease 
begins suddenly, with vomiting, high 
temperature, and several large, fluid 
stools. The vomiting does not often 
continue after the first twenty-four 
hours. The temperature is at first 

from 102° to 105° F., and its course may be steadily high (Fig. 58), 
or remittent. In some cases the constitutional symptoms — prostration, 
stupor, delirium, etc. — are so severe at the onset that the intestinal symp- 
toms are masked by them and an erroneous diagnosis is made. The abdo- 
men is usually tender and sometimes swollen. There is severe pain, and 



DAY 




12345, 


7 


3 






DATE 


JULY 


16 | 17 | 13 i 19! 20! 21 


22 


2 3 






t 


106° 
105° 
104° 


m.e 


M E 


M.E. 


M.E 


M.E 


M.E. 


M . E 


M.E. 


M.E. 


M.E, 










































z 

tt ! 103° 


\r 


1 






A 


( 


1, 


/ 






I 
< 

III 

tr 

l- 
< 
c 

a. 

E 
H 

ST 


102° 
101° 
100° 
99° 
98° 
97° 
96° 
OOLS 


y 




A 


A 


f\ 


J 


1/ 








= 


' 


\ 


/ v 






























r 

















































































7 


11 


? 


7 


J 


!4 


4 







Fig. 58. 



-Temperature chart of membra- 
nous colitis; fatal. 



350 DISEASES OF THE DIGESTIVE SYSTEM. 

at times almost constant tenesmus, during which prolapse of two or three 
inches of the mucous membrane of the rectum occurs. This is intensely 
congested, and sometimes shows patches of pseudo-membrane upon its 
surface, thus establishing the diagnosis. 

The stools resemble those of the catarrhal variety, except that blood is 
more constantly present and usually more abundant ; but the only posi- 
tive point of difference is the presence of shreds or patches of pseudo- 
membrane. If the stools are thoroughly washed with water, patches of 
membrane may be seen as gray opaque masses, which are then easily dis- 
tinguished from the transparent mucus. Large sheets of membrane are 
seldom discharged ; usually only small patches are found. Both blood 
and mucus sometimes disappear from the stools, which may consist only 
of dirty water. Under the microscope there may be seen epithelial cells, 
red blood-cells, and round cells in great numbers. 

The duration of the disease is usually a little less than two weeks. The 
course closely resembles that of the severe catarrhal form. There may be 
a continuous high temperature with severe intestinal symptoms and great 
prostration until death takes place from sepsis or exhaustion, or after 
three or four days the temperature may fall to 100° or 102° F., rising again 
at the termination of the disease. The most protracted fatal case I have 
known lasted four weeks. It is probable that almost every case of the 
severity described, terminates fatally when it occurs in an infant. In 
older children the prognosis is much better as to life, but in them the 
acute attack may be followed by the chronic form of the disease. 

Diagnosis. — Ileo-colitis is to be distinguished from typhoid fever and 
intussusception. In infancy a doubt between typhoid fever and ileo- 
colitis does not often arise. Cases of typhoid fever under twenty months 
are extremely rare, and are not likely to be seen unless the disease is epi- 
demic. I have never seen a case under this age. In children over two 
years, the two diseases are more likely to be confused. Typhoid is distin- 
guished by the slower invasion, more constant temperature, enlargement 
of the spleen, tympanites, and most of all by the eruption. The fact that 
the disease is epidemic is also to be considered. Acute colitis may be con- 
founded with intussusception. If the possibility of this mistake is kept in 
mind it will not often be made ; yet the records of intussusception show 
that a very large proportion of them were regarded in the beginning as 
cases of dysentery. In intussusception, although we have a sudden onset 
with acute pain, tenesmus, vomiting, and marked prostration, there is no 
fever. The later symptoms — absolute constipation, tumour, tympanites, 
rising temperature, stercoraceous vomiting, and collapse — have nothing in 
common with colitis. A diagnosis between the different varieties of ileo- 
colitis is not always possible. Follicular ulceration is distinguished by its 
lower temperature, rather subacute course, in frequency of blood in the 
stools, and by the fact that it is usually preceded by one or more attacks of 



ACUTE ILEO-COLITIS. 351 

acute gastroenteric infection, upon which its peer" 3 are grad- 

ually ingrafted. In both the catarrhal and the i arieties, the 

symptoms of an acute inflammation of the cole manifest from 

the outset — bloody stools, much pain, tenders mus, and fever. 

They differ chiefly in severity, and by the fact the the membranous 

form shreds of false membrane may be found in the stools. The course is 
shorter and the attack is altogether more intense than in the follicular 
form. Death often takes place in ten or twelve days, during the period of 
most acute symptoms. The protracted cases of catarrhal ulceration can 
not be distinguished from the more common ones of follicular ulceration. 

Prognosis. — This is much worse in infants than in older children. It 
is especially bad in cities, among the poorer classes, and in institutions. It 
is rendered unfavourable by previous rickets or malnutrition, and by the 
existence of any complication, particularly broncho-pneumonia. The 
prognosis is worse in children who have been badly fed, in those recently 
weaned, and in those who earlier in the season have suffered from attacks 
of diarrhoea. The particular symptoms which make the prognosis unfa- 
vourable in a case are continued high temperature, frequent vomiting, 
rapid wasting, an excessive amount of blood in the stools, severe nervous 
symptoms, and very weak pulse. These cases are never out of danger 
until the end of the hot season, on account of the great liability to re- 
lapses and recurrent attacks. 

Prophylaxis. — What has been said regarding general prophylaxis in the 
previous chapter, applies equally well to cases of ileo-colitis. Special em- 
phasis should be placed upon the necessity of energetic early treatment of 
all the milder forms of diarrhoea, and particularly the cases of acute gastro- 
enteric infection, in order that the process may be arrested before serious 
anatomical changes have taken place — a thing which is often possible. 
Equal stress should be laid upon the importance of prompt and radical 
treatment at the very beginning of the cases with a sudden onset. 

Hygienic Treatment. — The general plan recommended in the previ- 
ous chapter should be followed here. A change of air is desirable for 
every case as soon as the acute inflammatory symptoms have subsided. 
In the protracted cases which drag on a subacute course, this change will 
often do more than everything else. Some children do better at the sea- 
shore, and others in the mountains. If possible, patients should be kept 
in the country until the last of September. A return to the city during 
the hot season is usually followed by a second attack, and, if the patient 
has not quite recovered, relapses are almost certain. Plenty of pure fresh 
air is necessary in all cases. The indications for bathing are the same as 
in other cases of acute diarrhoea. It is undesirable to crowd these patients 
in institutions, as they always do better when they can be separated. The 
dietetic treatment during the acute stage is the same as in cases of acute 
gastro-enteric infection. Special stress should be laid upon stopping cow's 



352 DISEASES OF THE DIGESTIVE SYSTEM. 

milk at once. In the protracted cases the diet presents great difficulties, 
as the children have little or no appetite, and soon come to refuse every- 
thing in the shape of food that is offered. In infancy, the articles which 
are most to be depended upon are skimmed milk which has been com- 
pletely peptonized, beef juice, broths, and liquid beef peptonoids. In some 
cases rice or barley water are well borne ; in others, some of the malted 
foods, although these often increase the number of stools and have to be 
stopped on that account. Food which leaves little residue should al- 
ways be chosen. Infants, when very ill, are much more likely to take 
too little than too much food. A careful record should be kept of the 
amount actually taken in each twenty-four hours. When this is much 
below the requirements of nutrition, gavage (page 62) may be tried. 
Sometimes all food and stimulants may be advantageously given in this 
way. In no case should food be given oftener than every two hours, and 
usually the interval should be three hours, water and stimulants being 
allowed between the feedings. In older children the diet during the acute 
stage must be much the same as in infancy. At a later period, raw beef, 
kumyss, or matzoon will be found useful, and during convalescence boiled 
milk or milk gruels made with rice or barley. Special care must be 
given to the diet for a long time. For months after an acute attack the 
intestines are very easily deranged. Relapses are excited by changes in 
the temperature, by great fatigue or exhaustion, but most of all by im- 
proper feeding. Especially in older children should such articles be 
avoided as oatmeal, potatoes, corn, tomatoes, and all fruits. I have seen a 
single peach given to a child two years old, excite a dangerous relapse, and 
a few raisins a fatal one. 

Medicinal and Mechanical Treatment. — Cases, the early stage of which 
is marked by vomiting and thin diarrhoeal stools, are to be managed at the 
outset according to the plan outlined in the previous chapter — viz., free 
purgation, irrigation of the colon, and stopping all food. Lesions of 
any considerable severity are not often present before the second week. 
In the cases in which the symptoms of acute inflammation are evident 
from the outset, as shown by the frequent bloody and mucous stools with 
tenesmus and pain, the measures to be depended upon are castor oil and 
irrigation of the colon, and later opium and bismuth by the mouth. Cas- 
tor oil should be administered in a full dose at the outset — one drachm 
at six months, two drachms at one year, and half an ounce at four years. 
Its primary effect is to clear the intestines, and its secondary effect is pe- 
culiarly soothing to the inflamed mucous membrane. If the stomach is 
at all irritable, calomel one fourth grain every hour to six or eight doses, 
or a saline purgative, may be substituted. Opium is usually required on 
account of the pain and tenesmus. The dose should be regulated by the 
severity of these symptoms and by the frequency of the stools. The de- 
odorized tincture and morphine are, I think, preferable to other prepara- 



ACUTE ILEO-COLITIS. 353 

tions. Dover's powder may be used if the stomach is not irritable. Re- 
peated small doses are better than a single large dose. It is very important 
that opium should be withheld for at least twelve hours after the initial 
purgative. As the pathological process is principally in the colon, and 
most severe in the lower half of the colon, it can be much more effectively 
treated by injections than by drugs given by the mouth. Irrigation of 
the colon (page 63) is one of our most valuable means of treatment in 
these cases. It should be used in conjunction with the measures already 
referred to. For general purposes a tepid saline solution should be em- 
ployed (common salt one drachm to water one pint). At least a gallon 
should be given at one time ; it should be injected high into the colon 
through a long rectal tube, and early in the disease repeated at least twice 
a day. Where the tenesmus is very great and blood abundant, either hot 
water (106° to 110° F.) or ice water may be used, and later astringent in- 
jections. A large amount of a weak solution may be given and allowed 
to escape, or after irrigating with a saline solution, a smaller quantity — 
three or four ounces — of a much stronger astringent may be introduced 
high into the bowel and prevented from escaping by compressing the 
buttocks. The most useful astringents are tannic acid and hamamelis ; 
as a weak solution, half a drachm of tannic acid or one drachm of the 
fluid extract of hamamelis may be used to a pint of water ; and for a strong 
solution, the same quantity of the astringents to three or four ounces of 
water. Xitrate-of-silver injections should never be used in acute cases, 
and their advantage in chronic ones is questionable. In conjunction with 
opium, benefit is often seen during the early stage by the continued use of 
castor oil in small doses — i. e., ten drops in emulsion every two or three 
hours. 

For cases not influenced by the measure mentioned, or those not seen 
at the outset, bismuth should be tried, but it is of no use whatever unless 
large doses are administered. Two drachms of the subnitrate must be 
given in twenty-four hours to a child a year old, and proportionate doses 
for older children. This should be suspended in mucilage. Tenesmus 
and pain are sometimes relieved by the injection of three or four ounces of 
a starch solution to which from five to ten drops of laudanum are added. 
Severe tenesmus, when not controlled by the measures above mentioned, 
and when associated with prolapsus ani, is sometimes immediately re- 
lieved by cocaine suppositories. From one fourth to one grain of cocaine 
may be given, according to the child's age. 

Stimulants are needed in nearly all eases. There are no valid objec- 
tions to their use even in the youngest infant. The feeble digestion and 
assimilation of these patients compel us to use alcohol very frequently. 
Stimulants are indicated by a weak pulse, poor circulation, and great 
general prostration, no matter at what stage in the disease these symp- 
toms are seen. Old brandy is usually to be preferred. Generally not 



354 DISEASES OF THE DIGESTIVE SYSTEM. 

more than thirty drops every two hours are needed for an infant one 
year old, but for short periods a much larger quantity may be required. 
Brandy should always be diluted with at least six parts of water. 

In cases where symptoms have lasted two or three weeks, and the 
active symptoms have subsided, where the temperature is scarcely above 
100° F., and the stools reduced to four or five a day, it is wise to stop all 
medication and attend only to food and stimulants, with irrigation of the 
colon every other day. One is often surprised at this stage to find that 
his patients do better without drugs than with them. The prevailing 
tendency is to overdose cases of this type. Careful attention to diet, judi- 
cious stimulation, regular irrigation of the bowel every day or two, with 
change of air, will do much more than any amount of medication. 

During convalescence general tonics are required, such as arsenic, iron, 
nux vomica, and wine. Cod-liver oil should be deferred until the stom- 
ach and appetite are quite normal and the stools free from mucus. It 
should, however, be continued throughout the succeeding winter months. 

CHRONIC ILEO-COLITIS. 

This is rarely seen except as a result of acute ileo-colitis, which is 
usually catarrhal or follicular, as the membranous variety is so severe 
that the patients rarely survive the acute stage. In the catarrhal form 
there may be a chronic catarrhal inflammation of the mucous membrane 
only, or there may be catarrhal ulcers. In the follicular form ulcers are 
usually present. 

Lesions. — Catarrhal form. — In its milder type it is quite common, 
but in its severe grade it is exceedingly rare. There may be changes in 
a large part of the small intestine and in the stomach, as well as in the 
lower ileum and colon. 

The gross appearance of the intestine often differs very little from the 
normal. The mucous membrane is usually of a dull gray or slate colour. 
Pigmentation may occur as strias in the mucous membrane, but more fre- 
quently it is limited to Peyer's patches and the solitary lymph nodules ; 
these, as well as the mesenteric lymph nodes, are generally swollen. 

The microscopical changes are usually marked. The lesion is chiefly 
one of the mucosa. (Fig. 59). The important features are a disappear- 
ance of very many of the tubular glands, and in the small intestine of 
the villi also. There is a very marked cell proliferation in the adenoid 
tissue of the mucosa, and if the disease has existed long enough there may 
be a production of new connective tissue. The solitary lymph nodules 
show usually nothing but cell hyperplasia. The lesions are not uniformly 
distributed, but occur in patches throughout the intestine. When present 
in the. stomach, they are of the same kind as those described in the intes- 
tine, although rarely so severe. In milder cases the gross appearances may 
show very little change to the naked eye, except swelling of the lymph 



CHRONIC ILEO-COLITIS. 355 

nodules. Under the microscope there may be found more or less extensive 
cell infiltration of the mucosa, but rarely any destructive changes or new 
connective tissue. 

Ulcerative form. — This is rather rare, for the reason that in infancy a 
very large proportion of the cases die during the acute stage. 

The ulcers are nearly always of the follicular variety ; occasionally they 
are catarrhal. If the patient dies after an illness of from six to eight 
weeks, the appearances do not diifer essentially from those described in 
acute cases. If life is prolonged from two to four months, ulcers are found 
in various stages of repair, sometimes associated with the formation of 
small cysts. Follicular ulcers require from two to four months for cica- 
trization, and the broad catarrhal ulcers eve'n a longer time. It is very 
doubtful whether stricture ever results from these ulcers in children. 



Skdfba 





vry/ari^m 



|IV^^3fe|:fe \ ■'-.', '■■'■•'. '•. 'f^MS^^H 



V l Q 



Fig. 59. — Chronic catarrhal inflammation of the ileum. 

The lesions affect the mucosa, A, almost exclusively. It is somewhat thickened; there is 
extensive destruction of the tubular follicles, remains being seen at 7", T\ there is a great in- 
crease in the cells, and some new connective tissue in the mucosa. Large new blood-vessels 
are seen at C, C. History. — Delicate child, thirteen months old; diarrboeal symptoms for four 
months; during the first two weeks there was high fever: at death weighed eight pounds. 
The gross changes at the autopsy were very slight. The section is from the middle ileum. 

The mucous membrane shows almost invariably evidences of more or 
less extensive chronic catarrhal inflammation. One of the rarest lesions 
are cysts of the colon. Fully developed cysts I have seen but once. 
The child had an attack of acute ileo-colitis, which became chronic, last- 
ing about five months. He never regained his health, and died one year 
later from intercurrent disease. In the descending colon and rectum, 
about twenty cysts the size of a pea, and many smaller ones, were found. 
They had a thin, translucent covering. On section, a thick, transparent, 
gelatinous material escaped. They were situated in the submucosa, and 
were undoubtedly produced by the dilatation of some of the tubular glands 
whose orifices had been obliterated. 

Associated lesions. — The important ones are in the lungs, the most 
common being hypostatic congestion, subacute or chronic broncho-pneu- 
monia, more rarely pulmonary tuberculosis. It is rare to find the lungs 
perfectly healthy. The liver is often found extremely fatty in cases asso 
ciated with great wasting, but in no case have I seen hepatic abscess. The 



356 DISEASES OF THE DIGESTIVE SYSTEM. 

kidneys usually show a more or less intense cloudy swelling, and sometimes 
there may be well-marked nephritis. Dropsical effusions into the serous 
cavities are very rare. General tuberculosis is not infrequently the cause 
of death. 

Symptoms. — These cases are usually seen in the autumn, and com- 
prise those which have barely managed to live through the summer months. 
No definite line can be drawn between the acute and the chronic stages. 
Under the head of chronic cases, all those which have lasted over six weeks 
will be included ; although some become chronic in a shorter time. 

The symptoms of active inflammation have passed away ; the tempera- 
ture is usually normal ; there is no pain or tenderness. There is, however, 
no improvement in the general condition, and either the weight remains 
stationary, or the child continues to lose slowly until it is little more 
than a skeleton. The face is pinched, the eyes sunken, and the cheeks 
hollow. The lips are pale, often fissured, and bleed readily. The fontanel 
is depressed. The body is so small that the head seems much too large. 
Almost every vestige of fat may disappear from the subcutaneous cellular 
tissue of the trunk and extremities. The skin hangs in loose folds on the 
thighs. The abdomen may be distended and tympanitic, or retracted and 
soft. The mouth is often the seat of thrush, of catarrhal, herpetic, or 
rarely of ulcerative stomatitis. The tongue may be heavily coated, but is 
more often dry, glazed, and red. In rare instances sordes covers the 
lips and teeth. The teeth sometimes decay quite rapidly from the gen- 
eral malnutrition. Baginsky states that the progress of dentition is 
arrested ; but I have very often seen these infants, almost " living skele- 
tons," go on cutting teeth quite as steadily as under normal conditions, 
and Eustace Smith has made the same observation. 

Although they seldom cry for food, as a rule, these children will take 
nearly everything given them, and an almost unlimited amount. Notwith- 
standing that it is retained, the more they are fed the more rapid seems 
the wasting. Vomiting is not common, and seldom occurs except from 
overloading the stomach or during an acute exacerbation of the symptoms. 

The stools are rarely frequent ; five or six a day being the average ; 
often there may be only two or three a day for a week at a time. They are 
thinner than normal, but are not often fluid. They contain mucus of a 
green or brownish colour, usually in large quantity. Blood is rarely pres- 
ent. The stools are sometimes green, often greenish brown, sometimes a 
pale gray. Undigested food is always present in quantity, and upon the 
diet depends very much the gross appearance of the stool, the odour of 
which is almost always offensive, sometimes extremely so. Pus is found 
under the microscope, but is rarely visible to the naked eye. Nothnagel 
and Baginsky have called attention to a form of stools which they believe 
to be characteristic of wide-spread inflammation of the mucous membrane 
with atrophy of the tubular glands : they are of nearly normal consistence, 



CHRONIC 1LEO-COLITIS. 357 

homogenous, dark green or brown colour, and usually offensive ; they 
sometimes alternate with stools of a watery character ; under the micro- 
scope nuclei are found, but no unchanged epithelial cells ; the food-remains 
are sometimes unrecognizable, from the extent to which decomposition has 
taken place. 

Prolapsus ani is not so frequent as in the acute cases ; but when it 
occurs it is generally more difficult to control. Flatulence and colic are 
prominent symptoms in some cases, but absent altogether in many others. 
As a rule, there is neither abdominal pain nor tenderness. When the 
abdomen is enlarged it is usually uniformly, but sometimes shows marked 
epigastric prominence, which is more often from dilatation of the trans- 
verse colon than of the stomach. The skin of the abdomen often 
seems very thin ; dilatation of the superficial veins is rarely seen. The 
liver and spleen are generally normal in size, so far as can be made out by 
physical examination. Although the mesenteric glands are enlarged, they 
can not be felt through the abdominal walls. Enlargement of the inguinal 
and other groups of external lymphatic glands is rarely striking. The skin 
is loose, wrinkled, dry, and scaly, and in the worst cases frequently cov- 
ered with small petechia over the abdomen and lower extremities. 
About the anus, and over the sacrum, thighs, genitals, and sometimes 
feet, there are excoriations, and not infrequently ulcerations. The pulse 
is weak, the peripheral circulation is poor, and the extremities are cold 
much of the time unless artificial heat is applied. The respiration is 
usually shallow, and often irregular without any apparent cause ; it be- 
comes rapid from the development of pulmonary complications. The 
temperature is elevated only during exacerbations, or from inflammatory 
complications. A subnormal temperature is frequently met with. I have 
occasionally seen it 95° F. in the rectum. A continuous subnormal tem- 
perature is a very bad sign. The urine shows no constant changes. Dropsy 
may be present without albuminuria. The weight is stationary, or steadily 
falls to an almost incredible degree. I have seen one infant weighing but 
eight pounds at thirteen months; another, thirteen pounds at two years 
and four months. There are marked cachexia and extreme anaemia. 
Ulcers of the cornea are not uncommon. Nervous symptoms are always 
present. The children are cross and irritable, sleep badly, and frequently 
have a low, whining cry, which is continued much of the time. Sometimes 
they are dull, apathetic, and quite indifferent to their surroundings. Per- 
sistent opisthotonus is occasionally seen ; and there maybe contractions 
of the extremities, but rarely general convulsions. 

The duration of the disease is from two months to a year. Compara- 
tively few patients survive more than four months. The progress is irregu- 
lar, and marked by periods of improvement, during which for ;i time the 
patient may hold his own, or even gain in weight. Any trivial cause may 
excite a relapse, and the downward progress is rapid. Death often occurs 



358 DISEASES OF THE DIGESTIVE SYSTEM. 

during one of these exacerbations, or it may be due to broncho-pneumonia, 
tuberculosis, or slow asthenia. 

Diagnosis. — The problem usually presented is, whether the condition 
of the bowel is of itself a sufficient explanation of the general condition, 
or whether there is some underlying constitutional disorder, of which the 
diarrhoea is only one of the symptoms. It is important to distinguish the 
cases in which the cachexia is quite marked and convalescence slow — 
although ultimately resulting in complete recovery — from those which 
present at a certain stage almost identical symptoms, and yet go on 
steadily from bad to worse, terminating fatally. The difference in these 
cases is really a difference in the character and extent of the lesions. 
The first group are probably cases of superficial catarrhal inflammation, 
or of follicular inflammation which has not gone on to ulceration, these 
lesions being capable of repair. The second group are the cases of follicu- 
lar or catarrhal ulceration, in which complete recovery from the lesions is 
impossible, and repair only partial, if indeed any occurs. In distinguishing 
between these cases the most important guide is the nature of the symp- 
toms during the antecedent acute attack. The longer the acute febrile 
symptoms have lasted and the higher has been the temperature, the greater 
probably is the extent of the lesions, and the more severe their character. 

The diagnosis of chronic ileo-colitis from general tuberculosis is diffi- 
cult, particularly so from the fact that tuberculosis is not an infrequent 
sequel to the intestinal disease. The points in common are the existence 
of diarrhoea (which may occur in tuberculosis in summer apart from, the 
presence of intestinal tuberculosis), anaemia, cachexia, and the signs of con- 
solidation in the lungs ; these, in the one case, depending upon broncho- 
pneumonia, and in the other upon tubercular deposits. Tuberculosis is 
more likely to be met with in institutions, among the poor of cities, and 
in children previously delicate and with a tubercular family history. In 
chronic ileo-colitis the wasting and anaemia follow the intestinal symptoms, 
and are usually just in proportion to their severity. For the differential 
diagnosis of the pulmonary condition see the chapter on Pulmonary Tu- 
berculosis. Of the constitutional symptoms the most important differen- 
tial one is fever. This is rarely absent in general tuberculosis or in tu- 
bercular ulceration of the intestine if extensive, though it is not high and 
its course is very irregular. It is absent in chronic ileo-colitis, except from 
complications and from the occasional acute exacerbation. 

Prognosis. — The prognosis depends upon the child's previous consti- 
tution, upon the duration of the intestinal symptoms, upon our ability to 
carry out proper treatment, upon the presence of complications ; but, most 
of all, upon the severity and extent of the intestinal lesions. The pos- 
sibility of error always exists in estimating the gravity of the lesions, so 
that no case should be considered hopeless. Every physician who sees 
much of this form of disease, has met with cases so weak, so wasted, and 



CHRONIC ILEO-COLITIS. 359 

so anaemic that recovery seemed out of the question ; and yet after a few 
weeks, under favourable conditions, they have begun slowly to improve, 
and finally have gone on to complete recovery. If, however, continuous 
symptoms have existed for eight or ten weeks without any sign of improve- 
ment, recovery is extremely doubtful. The patient may linger for two or 
three months longer, but usually only to be carried off by the first acute 
disturbance which occurs. 

Treatment. — Little or nothing is to be expected from drugs. ~No 
greater mistake is made than to give these children week after week the 
various diarrhoea-mixtures, with the expectation that ultimately the for- 
mula which exactly meets the wants of the particular case will be found. 
Drugs are to be used only for the relief of special symptoms. Thus 
a dose of opium may be needed when the movements are unusually 
frequent, or castor oil once in four or five days when the stools are par- 
ticularly offensive. The essential and important part of the treatment 
consists in injections, careful feeding, stimulation, and change of air. 
Astringent enemata, however, are of considerable value. They should be 
given daily or every other day, but from time to time should be discon- 
tinued to see what the condition of the stools is without them. They 
should be used as described in the treatment of acute cases after irrigating 
the colon with a tepid salt solution (one ounce to the gallon). The 
stronger astringent solutions should be used, and held in place for half 
an hour. 

Alcoholic stimulants must be given in almost all cases, and they may 
be continued for a long time with advantage. Old port or sherry will 
sometimes do better than brandy or whiskey. The diet mentioned in the 
later stages of the acute cases should be continued. Usually we give that 
which the patient will take most readily. The predigested foods are use- 
ful ; so also are such beef preparations as bovinine, and the liquid beef 
peptonoids. Raw scraped beef may be used with great benefit. Fats and 
starchy foods should be excluded entirely or given in very small quantities. 
It is usually better to give the carbohydrates in the form of the malted 
foods. Kumyss and matzoon are useful. The diet must be carefully 
watched and directed according to the effect upon the stools of the various 
articles employed. In some of these cases nutrition may be promoted 
by inunctions of cocoa butter, cod-liver oil, or some other form of fat. 

The patient must first be put in the best possible surroundings ; in no 
disease is a change of air more to be desired than in this. These cases are 
trying ones to the physician; for unless he can absolutely control fche 
matter of diet, it is almost useless to attempt to do anything. Still, by 
careful study of the individual case and attention to minute details, suc- 
cess may sometimes be achieved even when the outlook seemed at the 
outset the most hopeless. The danger of relapses and second attacks 
continues long after the primary attack has sudsided. 



360 DISEASES OP THE DIGESTIVE SYSTEM. 

AMYLOID DEGENERATION OF THE INTESTINES. 

This is rarely met with in infants. It is not so infrequent in older 
children, where it is associated with amyloid changes in the liver, spleen, 
and kidneys, usually as a result of prolonged suppuration in connection 
with bone tuberculosis. It is sometimes met with in syphilis. The ileum 
is the part of the intestine most affected. The process begins in the walls 
of the arterioles and capillaries, particularly of the villi, and later involves 
the vessels of the submucosa ; subsequently the epithelium may be affected. 
The mucous membrane in these cases is pale, rather translucent. The 
condition is recognised by the application of the iodine test. This is best 
seen in the lower ileum, where the affected villi become of a brownish-red 
or mahogany colour. 

Amyloid degeneration produces no definite symptoms. Diarrhoea is 
frequent but by no means constant. The ansemia and waxy cachexia 
which are present are probably dependent much more upon the associated 
lesions of the liver and kidneys than upon the changes in the intestines. 
The treatment is symptomatic. 

TUBERCULOSIS OP THE INTESTINES AND MESENTERIC LYMPH 
NODES (MESENTERIC GLANDS). 

These two conditions are usually, but not invariably, associated, and 
may conveniently be considered together. 

Frequency. — In 109 autopsies of my own upon tubercular cases in 
which the condition of the intestines was noted, they were involved in 37 
per cent. The great majority of the patients were under three years of 
age. In 131 autopsies upon tubercular cases published in the Pendlebury 
Hospital Eeports, the intestines were involved in 50 per cent. These 
patients were mainly between four and fourteen years old, very few of 
them being infants. In 209 autopsies upon tubercular children, chiefly 
infants, reported by Miiller, the intestines were involved in 28 per cent. 
In 1,346 autopsies collected by Biedert there were intestinal lesions in 31*6 
per cent. These figures show that the intestines are not one of the most 
frequent seats of tuberculosis in children, and that it is rather less fre- 
quent in infancy than at a later age. It is most common from the 
third to the eighth year. The figures for tuberculosis of the mesenteric 
lymph nodes are nearly the same as those for the intestines. They 
were tubercular in 35 per cent of my own autopsies, and in 59 per 
cent of the Pendlebury cases. Miiller and Biedert do not give the pro- 
portion. 

Etiology. — In all or nearly all cases, the mesenteric lymph nodes are 
infected from the intestines. It is of course possible, but unlikely, that 
the infection may be through the general circulation. With tubercular 
ulcers of the intestine, the lymph nodes are, I think, invariably found by 



TUBERCULOSIS OF THE INTESTINES. 3^ 

inoculations to be tubercular; although they may not yet be caseous. 
The infection of the intestinal mucous membrane is from bacilli in the 
canal. Much stress has been laid upon tuberculous milk as a means by 
which children are infected. There is little pathological support to be 
found for the view that children often contract the disease in this 
way. In 119 autopsies upon tubercular children, chiefly infants, there 
was not found one in which the most advanced, and therefore presumably 
the primary, lesion was in the intestines or stomach. In 127 autopsies, also 
upon tubercular infants, Northrivp found the most advanced lesion in the 
intestines in but a single case. While infection from milk is possible, it 
is certainly extremely infrequent. In my own autopsies, intestinal lesions 
have been found only in marked cases of generalized tuberculosis. In not 
more than one fourth of the cases in which such lesions were present 
were they severe. They were usually associated with an advanced pul- 
monary process, and were doubtless due to swallowing tuberculous sputum. 

Lesions. — Intestines. — Tuberculosis usually affects the small intestine ; 
with very extensive disease the large intestine may also be involved, and 
exceptionally it alone may be affected. The disease in the small intestine 
is usually found in the jejunum, and in the lower ileum near the ileo- 
cecal valve. Of the large intestine, the caecum is most often diseased ; 
ulcers are often found in the appendix. 

If seen very early there may be only tubercular deposits, usually 
widely scattered, involving the solitary lymph nodules, or Peyer's patches. 
These appear as tiny yellow nodules. Usually, however, ulcers are present, 
and often only ulcers are seen. Their size and number vary greatly; 
there may be only five or six tiny ulcers, or there may be forty or fifty, 
the largest being two or three inches in diameter. They very frequently 
involve the Peyer's patches. The typical tubercular ulcer is of irregular 
shape, with rounded borders and with its longest diameter at right angles 
to the intestinal axis. When large, it may nearly encircle the gut. The 
ulcers are excavated ; they have overhanging, infiltrated edges of a deep 
red colour. The surface is covered with granulations. In those which 
have partly healed a distinct puckering of the intestine occurs, which is 
especially noticeable upon the peritoneal surface. The small ulcers involve 
the mucosa only ; the larger and older ones the submucosa and the mus- 
cular coats, and not infrequently also the serous coat. Perforation may 
occur, but rarely into the general peritoneal cavity, as a localized plastic 
inflammation precedes it. There may be adhesions of adjacent intestinal 
coils, and fistula? may form, owing to ulceration at their point of contact. 
With these severe cases there is always associated more or less extensive 
tubercular peritonitis, frequently of the ulcerative variety. lAkc other 
tubercular processes, the infiltration and ulceration may cease af any Bti 
and cicatrization follow. If the ulcers have been large, ones, there is 
always some narrowing of the lumen of the intestine. Stricture rarely 



362 DISEASES OP THE DIGESTIVE SYSTEM. 

results, because the patients die from the general disease before it has had 
time to occur. Monti has reported a case of obstruction at the ileo-csecal 
valve, due to an old tubercular cicatrix, in an infant of twenty-one months. 

Mesenteric lymph nodes. — Usually these tubercular lymph nodes are 
from half an inch to an inch in diameter ; occasionally they may reach 
the size of a hen's egg. From a fusion of several of them, tumours of 
considerable size may be formed. I have seen one as large as the head of 
a child at birth. 

The process is the same as that which occurs in other lymph nodes in 
the body. There is a tubercular inflammation, followed by caseation, 
softening, and abscess, or by calcification. Localized peritonitis is found 
in all the marked cases ; this is usually plastic, but may be suppurative 
when due to the rupture of an abscess. Pressure upon the vena cava 
may lead to dropsy in the lower extremities. Ollivier has reported a case 
in which thrombosis of the vena cava occurred. Pressure upon the portal 
vein may lead to ascites and dilatation of the superficial abdominal veins. 
There may be pressure upon the thoracic duct. 

Symptoms. — The symptoms of intestinal tuberculosis are exceedingly 
irregular. Ulcers are very frequently found at autopsy when there have 
been no marked intestinal symptoms ; this is especially true of the small 
ulcers seen in infants. On the other hand, diarrhoea is not uncommon 
in cases of advanced general tuberculosis where no ulcers are present. 
It is the most frequent symptom, and may be exceedingly obstinate. The 
stools do not differ essentially from those in chronic ileo-colitis, except 
in the occurrence of haemorrhages and in the presence of tubercle ba- 
cilli. Haemorrhages are not very frequent, but they may be so large as 
to be the cause of death. This occurred in one of my cases, an infant 
nine months old, the blood coming from a single ulcer in the ileum. 
Haemorrhage is more common in older children. In some cases localized 
abdominal pain or tenderness is present. In advanced cases the symp- 
toms of intestinal ulceration are usually mingled with those of peri- 
tonitis, and there are also present the enlarged mesenteric lymph nodes, 
which may aid in the diagnosis. In the vast majority of cases, these 
nodes are recognised only by examining the abdomen. They can rarely 
be felt unless they are at least an inch in diameter. In making palpation, 
the hands should be placed upon the abdomen laterally, and slowly brought 
together at the spine. The tumours are generally felt as irregular nodular 
masses, lying close against the spine, not movable, and sometimes tender 
on pressure. The other symptoms are due to the complications which 
have been already mentioned. 

Diagnosis. — The only positive evidence of intestinal tuberculosis is the 
discovery of the bacilli in the stools. In the absence of this evidence, the 
disease is differentiated from simple ileo-colitis, first, by the signs of tuber- 
culosis elsewhere in the body, especially in the lungs, these being almost 



CHRONIC INTESTINAL INDIGESTION. 363 

invariably involved ; secondly, by the slow onset and gradual development 
of the symptoms, while in chronic ileo-colitis an acute attack has almost 
invariably preceded. Large haemorrhages always suggest tuberculosis. 

The large mesenteric glands are recognised only as abdominal tumours. 

Prognosis. — This depends altogether upon the extent of the tubercular 
disease elsewhere, as it is extremely rare for the intestinal lesion to be the 
cause of death. Once formed, the ulcers probably remain, cicatrization 
being very rare, and then only partial. 

Treatment. — The only symptom which ordinarily demands treatment 
is the diarrhoea. When severe, this is to be managed much as in cases of 
ileo-colitis, except that irrigation of the colon is, of course, not called for. 
The chief reliance must be upon diet and internal medication. The 
drugs which are most useful are bismuth, opium, and creosote, which 
should be given in pills coated with shellac. 



CHAPTER IX. 

DISEASES OF THE INTESTINES .—{Continued.) 

CHRONIC INTESTINAL INDIGESTION. 

As the larger and more complex part of the process of digestion goes 
on in the intestine, so intestinal indigestion is a more common and more 
complicated disturbance than gastric indigestion. In many cases we find 
the two associated, but in perhaps the majority the symptoms relate en- 
tirely to the intestinal process. The conditions seen in young infants are 
so different from those in older children that the cases may be best con- 
sidered separately. 

In Young Infants. —The general causes are the same as those men- 
tioned in connection with chronic gastric indigestion : they are constitu- 
tional debility, either congenital or acquired, unfavourable surroundings, 
and previous attacks of acute disease. Chronic intestinal indigestion is 
especially common during the first six months, and is seen both in nursing 
infants and in those who are artificially fed. In the case of breast-fed 
infants the mother is often highly nervous, delicate, and anaemic, and is 
taking large quantities of fluids of every description, by means of which 
an abundant flow of milk is maintained. Why it is that the milk causes 
so much disturbance can not always be discovered even by the mosl care- 
ful analysis. The difficulty seems to be most frequently with the proteids, 
which are often in excess. Sometimes, proteids differing in character 
from those normally present seem to be produced, as the stools show that 
they are not digested. The microscope in some oases reveals the presence 
of many colostrum corpuscles in the milk. In another group of cases, 



364 DISEASES OF THE DIGESTIVE SYSTEM. 

where the condition of the nurses is all that can be desired, the trouble 
is simply that the milk is too rich ; it being then high both in fat and pro- 
teids. It may come, although rarely, from the fact that the child gets too 
much, being nursed either too frequently or for too long a time. 

In infants who are being fed upon cow's milk, the most common cause 
is that the proteids are too high ; this is usually the mistake when infants 
are fed upon plain milk which has been simply diluted. In other cases 
the fat may be excessive, as in many of the milk-and-cream mixtures in 
vogue. Sometimes both the fat and the proteids are too high. Next to 
this mistake in proportions, is that of over-feeding. When other sub- 
stances than cow's milk are used as foods, the usual trouble is that they 
contain a large proportion of starch. 

Lesions. — Strictly speaking, chronic indigestion is a functional dis- 
order without anatomical changes. Where the condition has lasted for 
many weeks or months, as often happens, there may result a low grade of 
catarrhal inflammation in the colon, attended by hyperplasia of the lymph 
nodules of the mucous membrane (Plate XI), and sometimes by a similar 
process in the mesenteric lymph nodes. Chronic indigestion may be the 
principal and the only symptom in cases of chronic ileo-colitis which have 
followed an acute attack. 

Symptoms. — The general symptoms are those of malnutrition, or in 
the more severe form, those of marasmus. These have already been fully 
described (page 204), and need only^be mentioned here. The most im- 
portant are stationary or losing weight, anaemia, poor circulation, often 
subnormal temperature, almost constant fretfulness and crying, with very 
little quiet sleep. The tongue is usually coated and the appetite often 
good, these infants taking food whenever given, and in an almost unlim- 
ited quantity. There are few cases in which occasional vomiting does not 
occur, but it is rarely persistent. So far as the intestinal condition is 
concerned, the cases may be divided into those with diarrhoea and those 
with constipation. It may happen that the same child will surfer for a 
long time from diarrhoea and then from constipation, or the reverse ; but 
usually one condition or the other is habitual. The diarrhceal stools 
are thin, green, and almost invariably contain curds, either in large lumps 
or small, flaky masses. They vary in number from three to ten in twenty- 
four hours. They are commonly passed without pain, although there 
may be flatulence. The stools have usually a sour, unpleasant odour, but 
they are rarely foul. They may be irritating to the skin, and cause 
troublesome excoriations or intertrigo. In some cases the stools contain 
but little solid matter, the character being that of yellowish-green water. 
In most of the cases, after the process has lasted two or three weeks, 
mucus is present, and may then become a constant feature. 

If there is constipation, the stools are usually gray or white ; they 
are smooth and pasty or like hard balls passed after much straining, often 



PLATE XL 




Chronic Hyperplasia of the Lymph Nodules (Solitary Poli n 
of the Colon. 

Child ten months old ; death from pneumonia without intestinal symptoms. Until 
live months old, nearly all stools were green or brown and contained mucus. 
The condition shown existed throughout the colon. 



CHRONIC INTESTINAL INDIGESTION. 355 

coated with mucus and sometimes streaked with blood. Often the bowels 
will not move for clays except after the use of laxatives or enemata. 
The latter often have but little effect, as the rectum may be empty. Con- 
stipated cases are especially prone to suffer much from flatulence and 
colic, the attacks of which may be very severe. 

The duration of these symptoms is indefinite. There is little or no 
tendency to spontaneous improvement, and they may drag on for several 
months or until the problem of diet is solved. The progress of these cases 
is marked by frequent exacerbations, during which there is vomiting, and 
usually fever. These symptoms are generally dependent upon intestinal 
toxaemia. A low irregular fever may continue for days or even weeks. 
Although the general symjDtoms of failing nutrition are present in most 
cases, a mild degree of chronic intestinal indigestion with frequent loose 
movements may sometimes last for months, during which the patients 
may gain steadily in weight and give every indication of being well nour- 
ished. This is much more common in nursing infants than in those who 
are artificially fed. 

Diagnosis. — It is not generally difficult to determine that an infant is 
suffering from chronic intestinal indigestion ; but one should endeavour 
to go further in his diagnosis and discover which of the elements of the 
food is causing the chief disturbance. Thus, in an infant fed on cow's 
milk, we wish to know whether it is the casein, the fat, or the sugar ; or, 
in another case, whether it is the starch of some proprietary food. Much 
valuable information may be gained from a careful history of what has 
already been tried in the case; often some gross error can be detected in 
the formula used or in the preparation of the food. Difficulty with the 
casein is usually shown by colic, constipation more often than diarrhoea, 
and by curds in the stools; often there is vomiting. Difficulty with the fat 
is indicated by loose movements, usually of a yellow colour. Sometimes 
they are white, smooth and formed, with a peculiarly offensive odour ; there 
may be vomiting or the regurgitation of food in small quantities. Diffi- 
culty with the sugar is less common than with either the casein or fat, 
but there may be colic and diarrhoea, with thin, sour, irritating stools. Diffi- 
culty with the starch leads to much flatulence and colic, diarrhoea alternat- 
ing with constipation, and offensive stools. One may find the foregoing 
symptoms in any combination, for in protracted cases the trouble is rarely 
limited to a single element in the food. If one is feeding cow's milk, the 
best way to arrive at a diagnosis is to begin with what would he a proper 
formula for a healthy infant for the age (page 174) and watch tie- si 
closely for two or three days. The proportion of the offending element 
should then be reduced until the symptoms it is causing disappear. By 
carefully modifying milk in this way, a diagnosis can usually be reached 
in a few days. Without it all treatment is haphazard experimen- 
tation. 



366 DISEASES OF THE DIGESTIVE SYSTEM. 

Prognosis. — This depends almost entirely upon how early the cases 
come under treatment and how they are managed. There is very little 
tendency to spontaneous improvement or recovery. The existence of 
chronic intestinal indigestion is one of the most important predisposing 
causes to more serious forms of intestinal disease, and in that consists its 
chief danger. 

Treatment. — Drugs have no part in the treatment of these cases, ex- 
cept now and then for particular symptoms, such as constipation or 
colic. These infants are cured by proper dietetic and hygienic measures, 
and by these alone. The problem of diet has already been discussed in 
the chapter on Infant Feeding (page 180). For the general management 
of the case, which is not less important, the reader is referred to the 
chapter on Malnutrition. 

In Older Children". — Chronic intestinal indigestion is exceedingly 
common in children from the first to the fourth year. It is, however, 
seen throughout childhood, but after the age mentioned it is much less 
frequent. The younger children have usually been badly fed from the 
time of weaning from the breast or bottle. The almost universal mistake 
is that an excess of carbohydrates has been given, particularly potato and 
oatmeal. In many children these articles have been the most important 
part of the diet. Children suffering from rickets are very much more 
prone to chronic intestinal indigestion than are others, but it is seen in 
many in whom there is no trace of rickets, and in all grades of society — 
quite as often among the better class as in dispensary practice, although 
the type is usually less severe. 

Symptoms. — The clinical picture which these cases present is a very 
common one, and the symptoms are quite uniform. Patients are gener- 
ally very thin, with very small extremities, a small amount of fat, and 
large, protuberant abdomens. There is much flatulence, and in cases of 
long standing there is marked tympanites. The children are pale, 
anaemic, and sallow in complexion ; they have dark rings under the eyes ; 
they are easily fatigued on slight exertion ; they are very cross, irri- 
table, and emotional to an unnatural degree. They are hard to amuse, 
hard to control, and altogether exceedingly difficult patients to deal with. 
Their growth is retarded if the symptoms have lasted long. They are 
much below the average in height and weight. Even when not rachitic 
they walk late, and their general development is very slow. The sleep is 
always unnatural and disturbed ; they can rarely be made to sleep with 
any regularity during the day, and at night they toss about their cribs, 
waking frequently, crying out and often grinding their teeth ; this some- 
times leading to the diagnosis of intestinal worms. They perspire very 
readily, and, like infants thus affected, they suffer from cold extremities. 

The bowels are usually constipated, the stools being of a light gray 
colour or perfectly white. They are always formed and generally lumpy. 



CHRONIC INTESTINAL INDIGESTION. 367 

The odour from the discharges is usually extremely foul. In other cases 
there is chronic diarrhoea. The stools are not very frequent, rarely ex- 
ceeding four or five a day, but they are large, thin, gray, green, or brown 
in colour, very offensive, and always contain undigested food. They are 
often excited by the taking of food. From time to time, in many 
patients, large quantities of mucus are passed from the intestine ; in some 
cases this comes to be a constant feature of the disease. It results 
from an intestinal catarrh, which has been set up by the irritation from 
the hard faecal masses or from the chronic functional derangement. 
Large quantities of gas are expelled per anum. Pain is not a very com- 
mon symptom in most cases, although in a few patients a localized pain 
of considerable severity may be complained of at certain times, lasting 
for a day or more. The appetite is capricious, and usually poor, but 
some patients will eat everything offered. Because of the disinclination 
to take simple food, the most indigestible and highly seasoned articles are 
often given, with the effect of increasing the severity of the symptoms. 
The tongue is often coated, although it may be quite clean ; the breath 
is foul. 

The nervous symptoms which these patients present are exceedingly 
varied, and often of the most puzzling character. In many cases they are 
so severe and so persistent as to lead to the diagnosis of organic disease of 
the brain. In addition to the condition of general nervous irritability, 
there may be opisthotonus, tetany, fainting attacks resembling some- 
what the seizures of petit mal, exaggerated reflexes, attacks of dulness or 
sometimes stupor, with retracted abdomen, irregular pulse and respiration, 
and other symptoms strongly suggestive of tubercular meningitis. Some 
patients have shown transient paralysis. Convulsions are not very un- 
common. Headache and frequent attacks of vomiting, which are perhaps 
to be interpreted as instances of migraine, are occasionally seen. In fact, 
there is almost no end to the complexity of these cases and the combina- 
tions of nervous symptoms which they may present. Most of these are 
toxic in their origin. The skin shows frequently eruptions of erythema 
or of urticaria. 

Slight fever, also of toxic origin, is sometimes present for many 
weeks, the temperature usually varying between 99° and 100-5° F. Some- 
times for several days it may be normal, and occasionally may rise to L02 c 
or 103° F. during a slight exacerbation in the symptoms. The urine of 
many of these patients contains a large quantity of indican; the amount 
present indicates very accurately the degree of intestinal putrefaction 
going on, and often fluctuates regularly with the nervous Bymptoms, 

Intercurrent attacks of acute indigestion, with diarrhoea and vomiting, 
are common and quite easily excited. The course; and duration of I 
symptoms are indefinite. In the most severe forms, if untreated, the pa- 
tients gradually waste until they die from exhaustion, or fall easy victims 



368 DISEASES OF THE DIGESTIVE SYSTEM. 

to any acute disease which they may happen to contract. There is but 
little tendency to spontaneous recovery. 

Prognosis. — This depends upon the duration of the symptoms, the 
general condition of the patient at the time treatment is begun, and upon 
how thoroughly it can be carried out. The symptoms, in the great 
majority of cases, have existed for several months at the time the case 
comes under observation. Generally, the greater the mistakes in feeding 
have been, and the more gross the violation of hygienic and dietetic rules, 
the better the prognosis. A child who has developed chronic intestinal 
indigestion of a severe type, in spite of the fact that the hygienic sur- 
roundings were good, and where the dietetic errors were not flagrant, is 
not nearly so hopeful a subject for treatment as one whose hygienic sur- 
roundings have been poor and whose diet has been especially bad. In 
cases like the latter, a removal of the causes and the institution of proper 
methods of treatment almost invariably result in immediate and striking 
improvement, unless the general vitality of the patient has been reduced 
to a very low point. In the other cases, where the mistakes have been 
less marked, and the condition is due more to constitutional than to local 
causes, the improvement is slower and less striking. Thus, as a rule, 
hospital patients improve more rapidly than those seen in private practice, 
because their previous treatment has been so much worse. 

Treatment. — In no class of cases that the physician is called upon to 
treat are results more satisfactory than in many of those of chronic intes- 
tinal indigestion, where the intelligent co-operation of the parents or a 
trained nurse can be secured. If the parents themselves are lax in disci- 
pline, and are unable to control the child, an efficient trained nurse should 
be secured, into whose hands the exclusive management of the child 
should be placed. The essential part of the treatment is that relating to 
diet. In the second and third years the most important thing is to stop 
all starchy food for a considerable time, and put the patient upon an 
exclusive diet of rare beef or beef juice and milk. The milk for many of 
the patients must be peptonized, as the casein of cow's milk is often very 
difficult of digestion even by children three years old. By some the fat 
also cannot be digested, and skimmed milk should then be used ; in very 
obstinate cases it should be peptonized for two hours ; in the majority of 
cases, however, it is sufficient to peptonize it from fifteen to twenty min- 
utes. Additional carbohydrates are often best given in the form of some 
of the malted foods, which may be continued until the child can digest 
some form of starch. The number of feedings should be five a day during 
the second year, and four a day for children during the third and fourth 
years. These should always be at regular intervals, and nothing what- 
ever given between meals. The meat should be rare scraped beefsteak 
or mutton ; from one to three tablespoonfuls may be allowed once a day. 
Fresh fruit, especially oranges, may usually be allowed once a day, given 



CHRONIC INTESTINAL INDIGESTION. 369 

one hour before meals. Kumyss or matzoon is often of very great value 
in children who are not fond of milk, or who become tired of the diet. 
Although at first they are taken with difficulty, in many cases a fondness 
for them is very soon acquired. Sometimes they are invaluable. 

After improvement has been going on for a month, bread may be added, 
at first in small quantities and once a day. This should preferably be stale 
bread, cut thin and dried in the oven until it is crisp, and given with- 
out butter. Two or three times a week raw oysters may be tried. Mutton, 
chicken, or beef broth, without vegetables, may be given occasionally in 
the place of one of the milk feedings. After this diet has been kept up 
for three or four months, if improvement continues, one of the green vege- 
tables may be added once a day, preferably either spinach, stewed celery, 
or asparagus. After two or three months more of continued improvement, 
thoroughly cooked rice or macaroni may be given twice a week. With 
these articles of diet one can get along very comfortably for a year, and 
no larger variety should be given until all the symptoms have disappeared. 
When starchy food is finally allowed, it should be only in small quantities, 
and usually with some preparation of malt. Potato and oatmeal should 
be forbidden for a long time. 

Intestinal irrigation (page 63) is useful in all cases in which there is 
much mucus passed. A saline solution should be employed. The irriga- 
tion should be given at first daily, and after a week or two every other 
day, and, later still, once or twice a week. This seems not only to exert 
a favourable influence upon the catarrh in the colon, but also upon the 
lower part of the small intestine. 

The constipation can usually be controlled by the diet mentioned. If 
not readily so, calomel should be administered occasionally, and abdominal 
massage employed. Calomel seems to exert a very marked influence upon 
the cases, even when the constipation is not severe. It is often wise to 
administer a full dose of this drug every five or six days. In some pa- 
tients, a purgative dose of castor oil given every few days, acts more satis- 
factorily than the calomel. It is sometimes objectionable, however, from 
its tendency to aggravate the constipation. 

Drugs directed toward the process of putrefaction are extremely un- 
satisfactory even in older children, but sometimes diminution in the 
amount of flatulence follows the use of salol or salicylate of soda in live- 
grain doses after meals. General tonics are required, and may add ma- 
terially to the improvement of the patients. Altogether the best one is 
mix vomica. It may be given in combination with tin 1 bitter wine of iron 
just before meals, three times a day. This increases the appetite and acts 
favourably upon the constipation. Cod-liver oil, particularly in the early 
stage, is badly borne, and aggravates the symptoms. It should he with- 
held in all cases until very marked improvement in the condition of the 
digestion is assured. 
29 



370 DISEASES OF THE DIGESTIVE SYSTEM. 

Relapses are easily excited by indiscretion in diet, and parents should 
be impressed at the very beginning with the necessity of adhering rigidly to 
the diet prescribed. It very often happens that the improvement which is 
seen after one or two months of careful treatment is so marked as to lead 
the parents to the belief that a cure has been accomplished, so that 
they relax their vigilance and allow improper articles of food — conditions 
which are almost certain to induce a relapse. If the case is an aggra- 
vated one, and the symptoms of long standing, it is wise to tell parents 
at the outset that a year's treatment is the minimum in which anything 
permanent can be accomplished. 

The general treatment of the patient must not be overlooked. Proper 
clothing, regular exercise in the open air, cool sleeping rooms, sponging 
every morning with cold water, are all of very great importance, and con- 
tribute almost as much to the results obtained as the local measures 
adopted. (See chapter on Malnutrition.) 

The improvement in the nervous symptoms of the patient is one of 
the first things noticed, and is often marked in a few days after the 
beginning of treatment. From an irritable, fretful, peevish child the 
patient is sometimes totally changed in disposition in two weeks, so as to 
become quiet, affectionate, docile, and playful. 

INTESTINAL COLIC. 

The term colic is applied to any severe paroxysmal pain occurring in the 
intestines. It may be due to many causes. The colic of lead and arsenic 
poisoning are both very rare in children ; but colicky pains are present in 
appendicitis, intussusception, ileo-colitis, and, in fact, in all the severe forms 
of intestinal inflammation. Colic may be due to swallowing certain sub- 
stances, especially foreign bodies and the seeds of fruits ; and in rare 
cases it may be excited by the presence of round worms when they are 
numerous. In all the conditions mentioned, colic is only one of the symp- 
toms, although it may be a very prominent one. 

The special and peculiar colic of infancy is that which is associated 
with flatulence, and is due to indigestion. Here it is a symptom only, but 
may be a most troublesome one. This form of colic belongs essentially to 
the first six months of life, and is more frequent during the first three 
months. It may be seen at any time when digestion is very feeble. Many 
young infants suffer from colic a large part of the time ; others have only 
occasional attacks, which are often repeated at a certain time in the day. 

The flatulence to which the colic is usually due, may be from decom- 
position in the food or intestinal secretions, or in both. It is seen quite 
as often in nursing infants as in those who are artificially fed. Any of 
the elements of the milk may be a cause of colic, but in fully four fifths 
of the cases it is the proteids. The colic of nursing infants is nearly al- 
ways due to the fact that the milk is excessive in proteids, or else that 



INTESTINAL COLIC. 371 

these are digested with special difficulty. If cow's milk is the food, it is 
the casein which is usually at fault. It is rare that the quantity of sugar 
present in cow's milk is sufficient to be a cause of colic ; but this may 
happen when sugar has been added, much more frequently with cane sugar 
than with milk sugar. It is extremely rare for the fat to be a cause of 
colic. In infants, whose food consists largely of farinaceous substances, 
colic is also very common. 

As a result of the decomposition taking place in the intestine, gas ac- 
cumulates, and, the intestines lackiug sufficient muscular force to expel it, 
distention follows. To this in part the pain is due. But spasm of the 
muscular walls of the intestine is also an element in producing the pain. 
In some of the most severe cases it is possible that the spasm may be accom- 
panied by a slight intussusception. Colic may occur without flatulence, as 
in cases when it follows cold feet or chilling the surface. In these cases 
also, muscular spasm appears to be the principal factor in causing the 
pain. Intestinal colic may occur alone, or it may alternate with or accom- 
pany gastric colic. 

Symptoms. — These are in most cases so typical as to be easily recog- 
nised. They are always more severe in delicate and highly-nervous chil- 
dren. In the severe attacks there are contraction of the features, the loud 
paroxysmal cry, subsiding for a few moments and then beginning with 
renewed intensity, drawing up of the lower extremities, and in male in- 
fants contraction of the scrotum. With these symptoms the abdomen is 
usually found tense and hard. With the expulsion of the gas, the symp- 
toms subside at once, and the child usually falls asleep. In the most 
severe attacks there may be considerable prostration, cold extremities, and 
perspiration. When the symptoms are less severe there is only continual 
fretfulness, and the child can not sleep. When colic is habitual there are 
very few hours in the twenty-four when the child seems to be entirely 
comfortable. In nursing infants there may at times be difficulty in dis- 
tinguishing the cry of colic from that of hunger, as infants suffering 
from colic will usually take food eagerly, and this is often followed by 
temporary relief. In colic, however, the pain soon returns, and often is 
more severe than before. The cry of colic is usually violent and parox- 
ysmal; that of hunger is apt to be prolonged and continuous, and is not 
accompanied by the other symptoms mentioned as indicating abdominal 
pain. In older children the less frequent causes of colic mentioned at 
the beginning of this article, especially appendicitis, Bhould be borne 
in mind. 

Treatment— When colic is due to flatulence of the intestine nothing 
given by the mouth has much effect in relieving the symptoms. ( lertainly 
food should not be given. The purpose of treatment during the attack is 
to assist the child to get rid of the gas; as this is usually in the colon, the 
most efficient means is by enemata. At first an injection of four or live 



372 DISEASES OF THE DIGESTIVE SYSTEM. 

ounces of lukewarm water should be used. If this is not successful, two 
ounces of cold water with half a teaspoonful of glycerin may be tried. 
This rarely fails to start peristalsis and expel the gas. In conjunction 
with these measures, dry heat should be applied to the abdomen by means 
of hot flannels or a hot-water bag, and the feet should be well warmed. 
In cases of colic not associated with flatulence, where the pain is probably 
the result of muscular spasm, opium in some form is required in addition 
to heat or counter-irritation. The treatment between the attacks and the 
treatment of habitual colic should be directed toward the indigestion, 
upon which they depend. 

CHRONIC CONSTIPATION. 

Constipation may be said to exist whenever the stools are less fre- 
quent, harder, and drier than normal. During the first six months in- 
fants usually have two movements a day. Many, however, have only one ; 
but if this is normal in character the child is not constipated. In other 
cases, although there are two and even three stools a day, they may all be 
small, dry, and hard, having all the characters of constipated stools, and 
the case should be treated accordingly. 

Etiology. — The causes of chronic constipation are many and far-reach- 
ing. It may be due to a diminution in the secretion of the intestinal 
glands or of the liver. The movements are then hard, dry, very light- 
coloured, and are associated with much flatulence and other signs of 
intestinal indigestion. Very often the principal factor in constipation is 
insufficient muscular contraction in the intestine. The faecal masses are 
then propelled so slowly and remain so long in the intestine that the fluid 
portion is absorbed, the residue becoming, in consequence, so dry and hard 
that it is difficult to evacuate. In other cases constipation depends upon 
the fact that there is insufficient volume to the stools, as may be the case 
when the food given leaves very little residue. Constipation may depend 
upon local causes, as, for example, where an evacuation of the bowels is 
resisted on account of pain from fissure of the anus or from haemorrhoids. 
Although not the primary cause, this condition may be sufficient to keep 
up the constipation indefinitely. It may, in rare cases, be due to a con- 
genital condition, such as a narrowing of the large intestine at some point. 
The most important causes of constipation may be grouped under two 
heads : diet, and conditions giving rise to muscular atony. 

Diet. — In breast-fed infants the trouble is usually a lack of fat and an 
excess of proteids in the milk. In those who are artificially fed it is often 
because the fat is too low, and sometimes because both the fat and the 
proteids are too low, the stool lacking volume. In other cases the cause 
of constipation is indigestion, in still others the use of " sterilized " milk. 
During the second and third years the cause may be too much cow's milk, 
particularly that which has been boiled, or the use of an excessive amount 



CHRONIC CONSTIPATION. 373 

of starchy food. As during the first year, the trouble with cow's milk is 
that it contains too much casein, the digestibility of which has often been 
rendered more difficult by the boiling. In older children the cause may 
be an excess of starchy food and a lack of sufficient green vegetables, meat, 
and fruit. 

Muscular atony. — The most common cause of muscular atony is habit ; 
in a large number of cases this is the principal, and often it is the only 
factor. If the inclination to have a stool is regularly disregarded it soon 
ceases to be felt. The ordinary irritation from faecal masses produces no 
effect whatever. The longer such a condition continues the more obsti- 
nate does it become. This is an important factor in all cases. Another 
potent cause of muscular atony is rickets. In this disease the muscular 
walls of the intestine sutler like the muscles of the extremities, and be- 
come incapable of doing their work. Again, any form of malnutrition in 
which there is feeble muscular tone may cause or aggravate constipation. 
It is often seen as a sequel to acute attacks of diarrhceal diseases, particu- 
larly when these have been prolonged. Want of sufficient muscular ex- 
ercise is a frequent cause. There are many children who rarely suffer 
from constijmtion in summer when they have plenty of out-of-door ex- 
ercise, who very often do so in winter when such exercise is wanting. A 
loss of muscular tone is not an infrequent result of the prolonged and in- 
discriminate use of purgative drugs or enemata. 

Symptoms. — In some cases no symptoms are present except the local 
ones, the general health being excellent and the nutrition in no way 
disturbed. In the majority, however, there are symptoms of greater or 
less severity, depending somewhat upon the cause of the constipation. 
There may be simply flatulence and colicky pains, or the irritation of 
the hardened faecal masses may produce a slight catarrhal inflammation 
of the sigmoid flexure and the rectum, so that mucus and even traces of 
blood may be passed with the stool. Haemorrhoids may develop even 
in infancy, and frequently the constant straining leads to the production 
of hernia. In many of the most obstinate cases there are from time to 
time nervous symptoms resulting from the absorption of various toxic 
materials from the intestine. There may be headache, d ulness, fretf ill- 
ness, disturbed sleep, and often associated signs of intestinal indigestion. 
The urine often contains indican in considerable quantity, ami there may 
be slight fever. This is more likely to be present in infants than in older 
children. In many cases it is hard to separate the symptoms due to the 
constipation from those which depend upon the indigestion with which it, 
is associated. 

Diagnosis. — This includes the discovery of the cause and the principal 
seat of the constipation. To arrive at the former the mosl careful and 
thorough investigation should be made of the child's diet and habits. It 
is not always possible to determine whether the seat of trouble is the rec- 



374 DISEASES OF THE DIGESTIVE -SYSTEM. 

turn, the upper part of the colon, or the small intestine ; but there are 
some symptoms that will aid us. If a suppository is almost immediately 
followed by a stool nearly or quite normal in character, one may be sure 
that the rectum only is at fault, and that it needs but a little extra stimu- 
lus to make it do its work. This is a very common condition in infants 
who are too young to make any voluntary efforts to have a stool. In such 
cases there are no other symptoms present. In others, the white or gray 
stools, marked flatulence, offensive breath, and general irritability, leave 
no doubt of the fact that the trouble is in the small intestine and depends 
upon indigestion. 

Prognosis. — This depends altogether upon the cause of the constipa- 
tion, and upon how completely circumstances will admit of its being 
removed. 

Treatment. — This is always difficult, and in obstinate cases must be 
continued for a long time. It is absolutely indispensable to have the co- 
operation of an intelligent mother or nurse. To establish the habit of 
regular stools should be the first step, for without this regularity nothing 
can be done. In infancy this can generally best be accomplished by sup- 
positories. An older child must be taught to heed the first impulse to 
evacuate the bowel. Eegular habits can hardly be formed unless the same 
time each day is chosen for the movement. That to be preferred is soon 
after the morning meal, as taking food into the stomach usually starts a 
peristaltic wave which is continued throughout the intestine, and of this 
advantage must be taken. Even in infants only a few months old the 
habit of regular stools is often easily formed if the child is put upon the 
chamber or chair invariably at the same hour. This will do much to pre- 
vent the formation of a constipated habit. In older children nothing 
should be allowed to interfere with the movement of the bowels. Break- 
fast should be early enough to allow ample time for this duty before the 
other engagements of the day. All children must be carefully watched 
in this respect, and nurses should be impressed with the importance of the 
early formation of proper habits. 

Food.— With nursing infants who get good breast-milk constipation is 
rare. Where the milk is low in fat and high in proteids, constipation is 
not uncommon. For the measures by which such milk can be improved, 
see page 1£4. Where the fat can not be increased by dietetic treatment 
of the nurse, the infant may be given immediately after nursing, from one 
half to two teaspoonfuls of cream, according to the degree of constipation. 

In feeding cow's milk, constipation is overcome by getting the exact 
proportions of casein and fat which are suited to the infant. With most 
infants during the early months from 2 to 3 per cent fat and 1 per cent 
casein succeed best ; with those a little older, from 3 to 4 per cent fat and 
1-5 per cent casein. During the last half of the first year 4 per cent fat 
and from 2 to 3 per cent casein will be found satisfactory. (See pages 



CHRONIC CONSTIPATION. 375 

174-176.) However, to feed a young infant upon 2 per cent fat and 
2 per cent casein — which is what is usually given when cow's milk is 
simply diluted once with water — almost invariably produces constipation. 
With most infants during the first year, constipation may be, if not cured, 
at least prevented by such a modification of the milk. This is generally 
easy if proper feeding is begun early ; but when the constipated habit 
has become firmly established a proper adjustment of the elements of food 
is often not sufficient. 

During the second year, children who suffer from constipation should 
have both cream and water added to the milk, so that, instead of the 3*5 
per cent fat and 4 per cent casein of plain milk, they get 4 per cent fat, 
and 3 per cent casein. (See formula IX, page 185.) These proportions 
can be obtained by adding two tablespoonfuls of cream to two thirds of a 
glass of milk, and filling up the glass with water. Further improvement 
may be brought about by reducing the quantity of starchy food, and add- 
ing more meat or beef juice, which is quite laxative on account of its salts. 
Fruits are valuable in all these cases ; baked apples, oranges, stewed prunes, 
grapes — especially the hothouse variety — and in summer, fresh peaches, 
plums, and pears, may be given in small quantities ; but all berries should 
be avoided. 

For older children who are upon a mixed diet the amount of starchy 
food should be moderate, oatmeal being perhaps the best cereal. Milk 
should be given rather sparingly, and even then may be advantageously 
modified as for the second year. It is sometimes advisable to stop milk 
altogether and give only cream, from four to eight ounces of which may be 
allowed daily. It may be used with the breakfast cereal, mixed with po- 
tato or rice, added to soups or broths, and taken in various other ways. 
All bread should be made from whole wheat or unbolted flour. Meat 
may be allowed freely, also all green vegetables, one of which should be 
given every day. All fruits allowed infants may be used, but in larger 
quantities, and in addition raw apples. Of the dried fruits, only dates, 
prunes, and figs are admissible, and these are better stewed than raw. 
Fresh fruit is preferably given in the morning, oranges being especially 
useful when taken on rising. 

Either hot or cold water, when taken an hour before breakfast, may be 
of considerable benefit to older children. The sparkling waters, like Vichy 
or Apollinaris, are often better than plain water. 

Massage, when properly employed, is useful in conjunction with other 
measures, but rarely succeeds alone. It should be given for five or ten 
minutes after retiring and just before rising. The hand must be warm, 
but no oil used, the purpose being not to make friction upon the skin, 
but to move the skin and abdominal walls upon the intestines. This 
should be done with a circular motion, changing the point from time fco 
time until the whole abdomen has been thoroughly covered. In addition to 



376 DISEASES OF THE DIGESTIVE SYSTEM. 

this a general kneading of the abdomen may be employed. Only slight 
pressure should be made until the child becomes accustomed to the process, 
when quite deep pressure will be tolerated. The intestinal coils may often 
be felt contracting under the hand during massage.* In general torpor 
of the intestines massage is useful, and when properly done may affect the 
small as well as the large intestine. 

A proper amount of active muscular exercise is necessary and should 
be made a part of the treatment in every case. Yale (New York) has 
called attention to the importance of posture during the stool, he having 
found that in many cases a cure was effected simply by substituting a low 
seat on a nursery chair or closet for the high one previously used. The 
low seat afforded the child an opportunity to strain to some purpose, while 
the higher one with the legs dangling, made this almost impossible. 

Suppositories. — In many cases, particularly in young infants who are 
not old enough to initiate the muscular effort, a slight stimulus to the rec- 
tum is all that is required. The cone of oiled paper has a great reputa- 
tion in domestic practice and is not objectionable. It may be of assistance 
in establishing the habit of a daily movement at a regular time. Soap sup- 
positories produce a more marked irritation ; although their immediate 
effect is quite satisfactory, they should not be continued indefinitely. They 
are, however, less objectionable than glycerin suppositories. The lat- 
ter, for an immediate effect, are convenient and usually efficient; but 
their prolonged use, especially in infants, is likely to set up a catarrhal 
proctitis. The gluten suppositories produce less irritation and are conse- 
quently slower in their effect, but they have not the disadvantages of the 
soap or glycerin. Medicated suppositories are certainly one of our most 
efficient measures ; if drugs must be employed, they are perhaps open to 
the fewest objections when used in this way. The following are the best 
drugs for this purpose, the dose being that for a child of two or three 
years : ext. nux vomica, gr. T ^ ; ext. belladonna, gr. fa '•> ex ^- hyoscyamus, 
gr. fa ; sulphur, gr. ij ; purified aloes, gr. J ; aloin, gr. fa. A good com- 
bination is aloin, gr. -fa ; ext. belladonna, gr. fa ; ext. nux vomica, gr. -fa ; 
ol. theobrom., gr. x. In obstinate cases this may be used night and morn- 
ing, and later at night only. After some improvement has occurred the 
aloin may be omitted. Many of the proprietary suppositories contain the 
ingredients mentioned, particularly belladonna, the dose of which is often 
considerably larger than should be given. Suppositories are most useful 
where the seat of trouble is the rectum and lower colon ; but very little is 
to be expected from them when it is in the small intestine. 

Enemata. — These should be restricted to cases in which only temporary 
relief is desired. An injection of an ounce of sweet oil may facilitate the 
passage of very hard and dry stools, and larger injections of soap and water 

* See Karnitzky, Archiv fur Kinderheilkunde, Bd. xii, p. 66. 



CHRONIC CONSTIPATION. 377 

may be used to break up hard fascal accumulations. For immediate effect 
an injection of one drachm of glycerin in half an ounce of water is perhaps 
the most efficient means at our command. Cases of fascal impaction are 
rarely met with in children. They are to be managed as in adults, by 
repeated injections of warm water or of ox-gall, and sometimes by me- 
chanical removal. For continuous use enemata are not to be advised, for 
larger and larger quantities are required to produce the effect. 

Medicinal treatment. — This is the least important part of the manage- 
ment of chronic constipation. No plan is worse than to give some active 
purgative every third or fourth day and trust matters to take care of them- 
selves the rest of the time. The most valuable drugs are those which 
stimulate the muscular walls of the intestine, such as cascara, mix vomica, 
belladonna, and hyoscyamus. These are particularly useful in atonic con- 
stipation associated with rickets and following diarrhoeal diseases, but they 
are valuable in all cases. With most drugs the prolonged use of small 
doses is better than the occasional use of large ones. Calomel is indicated 
in cases attended with dry, very white stools and marked flatulence ; 
one fourth to one half grain of the tablet triturates may be given for two 
or three successive nights in conjunction with other means. Cascara may 
be used either in the form of the elixir, dose from one half to one drachm, 
or the fluid extract, from one to five drops. Rhubarb, either in the form 
of the syrup or the mixture of rhubarb and soda, may be given occa- 
sionally, but it is not adapted to continuous use. Of salines, phosphate 
of soda is best for continuous use in infants. All the preparations of 
malt possess slight laxative properties, and are useful in conjunction with 
dietetic and other medicinal means; either Trommer's extract of malt 
or maltine may be employed. Castor oil should on no account be given 
for chronic constipation. The frequent use of small quantities of olive 
oil is often a good means of treatment in the case of young infants, the oil 
being added to the food. 

Summary. — The treatment of constipation is palliative and curative. 
The palliative measures are drugs, suppositories, injections, and enemata. 
Cure is accomplished only by diet, massage, exercise, and the formation of 
regular habits. An average case of chronic constipation in a child four 
years old maybe managed as follows : Massage for eight minutes, morning 
and night; the juice of half an orange and a glass of Vichy immediately 
upon rising; a breakfast of oatmeal with one ounce of cream, dried bread 
with butter, an egg, half a glass of milk with cream and water added; 
a dinner of soup, one starchy v%etable — e. g., potato with cream, and 
one green vegetable, beef-steak, baked apple or prunes, dried bread and 
butter, and water to drink ; for supper, cream-toast, egg, dried lucid and 
butter, or Graham crackers, half a glass of milk with cream and water 
added ; a suppository containing mix vomica and hyoscyamus given at 
bedtime. - 



378 DISEASES OF THE DIGESTIVE SYSTEM. 

Hypertrophy and Dilatation of the Colon. — It is probable that in many 
cases of chronic constipation, especially among rachitic infants, a consid- 
erable degree of dilatation of the colon occurs. However, it seems to be 
but a temporary condition, disappearing by the third or fourth year. 

There is another form of dilatation which may be permanent ; it is 
associated with a marked degree of hypertrophy of the muscular walls of 
the colon. The reported cases thus far are few in number, but have been 
observed both in infants (Hirschsprung,* Myaf) and in older children 
(Osier, Hughes t). The prominent symptoms are two: obstinate con- 
stipation, which in most of the cases has continued from early infancy, 
and is sometimes so severe that the patients have gone for two weeks 
without a movement of the bowels ; and distention of the abdomen, which 
may be extreme, but which may disappear and the abdomen become per- 
fectly flat after the faeces and flatus have been discharged. There is usu- 
ally emaciation, and from time to time there may be diarrhoea. Death 
may occur in infancy, or the patients may live to adult life. 

In the cases which have come to autopsy there has been found an 
enormous dilatation of the large intestine, chiefly of the transverse colon 
and the sigmoid flexure. In one case (Hughes'), in a boy of three years, 
the colon was four inches in diameter, and held fourteen pints of water. 
In none of the cases was there stricture at any point. The mucous mem- 
brane has invariably been found ulcerated, this clearly being a secondary 
process. The muscular walls have been greatly hypertrophied. The con- 
dition is without doubt a congenital one. Treatment is palliative only. 
In some of the cases the condition seems to have been aggravated by the 
use of large enemata. 

INTUSSUSCEPTION. 

Intussusception consists in the invagination of one portion of the 
intestine into another. It occurs most frequently in infancy, being at 
this age the most common cause of acute intestinal obstruction. The 
accident is not a common one, but the life of the patient generally depends 
upon its prompt recognition. 

Varieties.— Usually the upper part of the intestine is invaginated into 
the lower, although the reverse is occasionally seen. Intussusceptions may 
occur at any point in the intestinal tract. Those of the small intestine 
are called enteric ; those of the colon, colic ; and those occurring at the 
ileo-caecal valve, ileo-cmcal (Fig. 60). Of 90 cases under ten years of age, 
in which the variety was determined by autopsy or operation, 75 were 
ileo-csecal, 9 colic, and G enteric. In the ileo-caecal form a few inches 

* Hirschsprung, Jahrbuch fur Kinderh., Bd. xxvii. p. 1. 

f Mya, Revue Mensuelle des Maladies de l'Enfance, vol. xii, p. 633. 

% Osier. Archives of Paediatrics, vol. xi, p. 112. 



INTUSSUSCEPTION. 



379 



of the ileum pass through the ileo-caecal valve, and then invagination of 
the colon occurs. Cases in which the ileum passes through the valve, but 
without invagination of the colon, are sometimes classed separately as an 
ileo- colic variety. 

Intussusceptions of the dying, as they have been called, are met with 
in my experience in about eight per cent of all autopsies made upon in- 
fants ; they are not often found in children over two years of age. They 
are distinguished by the fact that they are always descending, enteric, and 




Ku.. 60. — Ileo-caecal intussusception. 



A specimen removed from 
[nfanl Asylum. 



■Iiil.l in the New York 



multiple — usually from eighl to twelve invaginations being present. They 
are more frequently in the jejunum than in the ileum. They usually in- 
volve but two or three inches of the intestine, bul may include ten <>r 
twelve inches. They are found in autopsies upon patients dying of all va- 
rieties of disease, and are probably produced in the death agony. These 
intussusceptions are without symptoms, and are of no clinical importance. 
Etiology. — Of 385 collected cases under ten years, the following are 



380 DISEASES OF THE DIGESTIVE SYSTEM. 

the ages reported : under four months, 28 cases ; from four to six 
months, 113; seven to nine months, 71 ; ten to twelve months, 18; one 
to two years, 32 ; two to ten years, 96. Three fourths of the cases 
which occur in childhood are, therefore, in the first two years, and one 
half of them between the fourth and ninth months. The greater fre- 
quency in infancy is attributed to the thinness of the intestinal walls, the 
greater mobility of the caecum and ascending colon, and the presence 
of other intestinal derangements at this age. 

Males are more' often affected than females. Of 268 cases in which 
the sex was mentioned, there were 174 males and 94 females. For this 
fact there is no explanation. The exciting causes of an attack are ex- 
tremely obscure. The great majority of cases occur in children who were 
apparently in perfect health. Some previous intestinal disorder was pres- 
ent in about three per cent of the cases I have collected — diarrhoea, dysen- 
tery, colic, chronic indigestion, and constipation, all being mentioned. In 
four cases the intussusception was ascribed to injury of the abdomen. 
The association with the general diseases is too infrequent to be of any 
importance. 

Lesions. — jNTothnagel's vivisection experiments * have shown conclusively 
that intussusceptions are formed by the irregular action of the muscular 

walls of the intestine. They can be 

- — ^ produced or released at will by vary- 

_______^- 2/ i n g * ne application of the electrical 

Fia 61 current. In the artificial intussus- 

ception there is first a contraction 
of a certain part of the intestine, and if this ceases abruptly the normal 
gut below this point turns upward and folds over upon the contracted 
portion, thus forming a minute intussusception (Fig. 61). When once 
begun, the intussusception increases solely at the expense of the external 
layer (Fig. 62). Thus, while the apex of the tumour D remains un- 



Fig. 62. — Mechanism of intussusception. (Treves.) 

changed, the part of the sheath at A passes to B and then to C, so that 
the lower part of the intestine is drawn over the upper, rather than the 
upper crowded into the lower. The mechanism of the invagination was 
apparently the same when a part of the intestine was first paralyzed by 

* Beitriige zur Physiologic und Pathologie cles Darms, Berlin, 1884. A full abstract 
is to be found in Treves's Intestinal Obstruction, London, 1884, to which I am indebted 
for many points in this article. 



INTUSSUSCEPTION; 381 

crushing, as in the cases in which a spasm of the intestine was first pro- 
duced. 

There is no doubt that pathological intussusceptions are produced in 
the same way as in these experiments. As the invagination takes place, 
the mesentery is drawn in with the bowel, and always lies between the 
sheath and the inner layer. To allow intussusception to occur, the mes- 
entery must be unduly long, stretched, or lacerated. Its attachment to 
the spine causes the intussusception to describe an arc of a circle, the con- 
cavity of which is always toward the spine. It also causes a puckering 
of the tumour. Invagination does not necessarily produce either obstruc- 
tion or strangulation, but usually both are present, and are the chief 
causes of the symptoms. Traction upon the mesentery leads to obstruc- 
tion in its vessels, causing congestion, oedema, haemorrhages, and even 
gangrene. Obstruction is chiefly due to swelling. It may be due to 
dragging of the mesentery, which brings the apex of the tumour against 
the side of the gut, or to bending of the intussusception. 

The great cause of irreducibility in the first two or three days is swell- 
ing. I have several times seen at autopsy or operation the intussuscep- 
tion easily reduced, except the last two or three inches of the caecum or 
ileum, which was swollen to the thickness of from a fourth to half an 
inch. Adhesions may prevent reduction, but rarely before the fourth day ; 
they are often absent as late as the sixth or seventh day. They are usually 
between the internal and middle layers of the intussusceptum, and are due 
to local peritonitis. In chronic cases, however, they form the principal 
obstacle to reduction. Other causes of irreducibility are twisting of the 
tumour and pinching of the prolapsed intestine, especially of the ileum 
by the ileo-caecal valve. 

Gangrene and sloughing of the gangrenous portion of the intestine 
occur much more often in acute than in chronic cases. Portions of 
intestine were passed per anum in 24 of 302 cases under ten years, or 
about six per cent ; but only two of these were in infants. Toward the 
end of the second week is the time when the separation of the sloughs is 
to be looked for. The amount of intestine discharged, varies from a few 
inches to several feet. Two cases are on record in which the entire colon 
was passed, the patients recovering, but dying several months later from 
other causes. At the autopsies the ileum was found attached to the lower 
part of the rectum just above the anus. In acute cases gangrene occurs 
about the upper end of the tumour, and the intestine usually com.- away 
in one large mass. In chronic cases shreds of intestine may be discharged 
for several weeks. 

Symptoms. — The clinical picture of a case of intnssnsceptioi 
striking one, and when acute the symptoms arc bo uniform that, once 
seen, they can scarcely be overlooked a second fcime. The patient, 
usuallv between six and twelve months of age, is taken suddenly ill 



382 DISEASES OF THE DIGESTIVE SYSTEM. 

with severe pain and vomiting; the pain recurring paroxysmally every 
few minutes, and the vomiting being first of the contents of the stom- 
ach, and afterward bilious. There may be one or two loose faecal stools, 
then only blood or blood and mucus are passed without any admixture of 
faeces. The general symptoms are those of great prostration, or even col- 
lapse — pallor, feeble pulse, apathy, and normal or subnormal tempera- 
ture. The abdomen is relaxed. A tumour is present in the left iliac 
fossa, or it is felt per rectum. Later there is tympanites ; the vomiting and 
pain continue ; there is a steady increase in the prostration, and toward 
the end a rapidly rising temperature, which may reach 105° or 106° R 
before death occurs from collapse. If the symptoms continue longer the 
signs of peritonitis are added. In subacute cases the onset is less abrupt, 
and pain, vomiting, and constipation less constant and less severe ; but 
the same symptoms are present. In chronic cases the onset is with vague, 
indefinite intestinal symptoms ; pain, vomiting and bloody discharges are 
usually wanting ; there are progressive wasting and more or less diar- 
rhoea, but only the presence of the tumour leads to the recognition of 
the disease. 

Onset. — Of 193 cases under ten years in which data upon this point 
could be obtained, the onset was sudden in 181 and gradual in 12 cases. 
By far the most frequent symptoms of onset are pain and vomiting. In 
a smaller number of cases the initial symptom is diarrhoea or a discharge 
of blood and mucus. 

Pain. — This is rarely continuous, but is intermittent, recurring in 
paroxysms like those of ordinary colic, but of great severity. No pain in 
infancy is to be compared with it. The child often shrieks so as to be heard 
all over the house. Pain is a prominent symptom in over three fourths 
of the cases, and is very rarely absent. It is generally more marked for 
the first two days, but may continue throughout the attack. In a few 
cases the pain is localized, being usually referred to the region of the um- 
bilicus. 

Vomiting is more marked at the onset, but may continue throughout 
the disease. Like pain, it is more frequent in the acute cases. It is due 
to intestinal obstruction. Vomiting is present in fully four fifths of all 
cases. Usually it is persistent and uncontrollable ; it is often projectile. 
If food is given, vomiting often occurs as soon as it reaches the stomach. 
Stercoraceous vomiting occurs in about fifteen per cent of the cases in 
children under ten years, but is not common in infancy. It is rarely pres- 
ent before the third or fourth day. Although a bad sign, it is not by 
any means a fatal one, as nearly one half the cases in which it has been 
noted have recovered ; it is to be regarded as indicating complete intes- 
tinal obstruction rather than strangulation. 

Tumour. — This is one of the most important symptoms for diagnosis 
because of its frequency and its peculiar character. It is present early in 



INTUSSUSCEPTION. 



383 



the disease, often in a few hours after the initial symptoms. The follow- 
ing table shows the frequency with which a tumour was present in the 
different varieties, and the position which it occupied in each. The an- 
atomical variety was determined either by autopsy or operation. 



The Relation between the Tumour and the Different Varieties of Intussus- 
ception in 188 Cases under Ten Years. 







SEAT OP INTUSSUSCEPTION. 




Seat of Tumour. 


Ileo- 
cecal. 


Ileo- 
colic. 


Colic. 


Enteric. 


Not 
stated. 


Total. 


Region of caecum 


i 

3 
3 
4 
25 
9 

'i 


3 

i 


i 

7 

1 


1 

'i 

l 


7 
12 
13 
18 

8 

28 
12 

2 


11 


" " ascending colon .... 
" " transverse colon.. . . 
" " descending colon .. . 
" " sigmoid flexure .... 
Rectal 


13 
16 
21 
13 
61 


Protruding from anus 

Umbilical region 


22 
1 


Movable 


3 


Site unknown 


1 






Total 


46 

10 


4 
2 


9 


3 

1 


100 
13 


162 


No tumour felt 


26 







Tumour was thus made out during life in eighty-six per cent of the 
cases; and in the great majority of these it was discovered at the first 
careful examination. 

It will be noted that in one half of the cases the tumour was either 
felt in the rectum or protruded from the anus, and that in over two thirds 
it had advanced as far as the descending colon or beyond. The tumour 
may reach the rectum in a surprisingly short time, even when the invagi- 
nation begins at the ileo-caecal valve. In one of my own cases it was felt 
in the rectum in less than twelve hours from the onset. The usual de- 
scription, " sausage-shaped," is accurate when the invagination is large, the 
tumour then being from four to six inches long and about an inch and a 
half in diameter. It is often curved. 

During manipulation, or during an attack of pain, the tumour may be- 
come more prominent and may be distinctly erectile. To the touch the 
rectal tumour closely resembles the os uteri, the central opening being the 
apex of the intussusception. When protruding from the body, the tu- 
mour is rarely more than two inches long. It is usually of a deep purplish 
colour, and may be gangrenous. It lias been mistaken for prolapsus am, 
polypus, and even haemorrhoids. In ;i case which came subsequently 
under my observation, the tumour was discovered by the mother before 
the physician had suspected the condition. 

Condition of the bowels— Bloody stools area very constant symptom. 
Of 186 cases under ten years in which this condition of the bowels was 



384 DISEASES OF THE DIGESTIVE SYSTEM. 

noted, blood in the stools was present in seventy-six per cent. There are 
very often two or three thin, diarrhoeal movements, and then only blood 
and mucus are passed with no trace of faeces and with no faecal odour. 
The amount of blood varies from a quantity sufficient to stain the mucus 
to an ounce of semifluid blood. It rarely occurs without some mucus. 
Such discharges frequently follow attacks of severe colicky pain, and may 
occur several times in an hour. They may continue, or after a day or two 
they may be succeeded by absolute stoppage. Diarrhoea throughout the 
attack is rare in children, particularly so in infants. It belongs generally 
to chronic cases. Constipation is complete in most of the acute cases, 
neither gas nor faeces being passed ; a fact which the discharge of blood 
and mucus may lead one to overlook. 

Tenesmus is very common if the tumour is rectal. Eelaxation of the 
sphincter is met with in a considerable proportion of the cases when the 
tumour is in the sigmoid flexure, or rectum. 

During the first twenty-four or forty-eight hours the abdominal walls 
are soft and relaxed, and may even be retracted. Usually there is then 
little resistance to abdominal palpation. After the second or third day 
there is tympanites; but this does not necessarily mean that peritonitis 
exists. Localized tenderness is a symptom of some importance when a 
tumour is absent. Scanty urine has been noted in a few cases, but is of 
no special value in showing the seat of obstruction. 

In the acute cases the general symptoms are very striking. They are 
the ordinary ones of severe shock — marked prostration, pallor with an 
anxious expression of the face, general muscular relaxation, cold extrem- 
ities, cold perspiration, and often a subnormal temperature. Early there 
is marked restlessness, and even convulsions may occur. Later there are 
apathy, dulness, and semi-stupor. The temperature during the first twenty- 
four hours is usually not elevated, and is frequently subnormal. Toward 
the close of the disease it rises rapidly to 103°, 104° F., or even higher, 
quite independently of peritonitis. A rapidly rising temperature is always 
a bad symptom, and usually betokens death within twenty-four hours. 
Wasting is seen in the chronic cases, and may be quite rapid. 

Course, Duration and Termination.— Of 198 cases under ten years, 155 
were classed as acute, lasting less than seven days; 33 as subacute, last- 
ing from one to four weeks ; 10 were chronic, lasting over four weeks. 
Nearly all the cases occurring in infancy are acute. The duration of the 
disease in 92 fatal cases was as follows : less than twenty-four hours, 2 
cases ; two to four days, 44 cases ; five to seven days, 22 cases ; one to two 
weeks, 18 cases ; two to three weeks, 6 cases. Thus one half the cases 
died upon the third, fourth, or fifth day. Of 57 cases terminating in 
recovery, 66 per cent were reduced in the first or second day. (See table, 
page 386.) 

Spontaneous reduction is, without doubt, possible in intussusception. 



INTUSSUSCEPTION. 385 

Treves and others are of the opinion that this happens much more fre- 
quently than is generally supposed, and that many cases of severe colic are 
really cases of slight intussusception. There are seen in both conditions 
the tendency to vomit, the paroxysmal pain, the constitutional depression, 
and often the sudden cessation of the symptoms, especially under the 
influence of opium ; but to make a positive diagnosis of invagination in 
such cases is impossible. Intussusception may be cured spontaneously by 
sloughing of the invaginated part, the continuity of the intestine being 
preserved by adhesions. Such a result is rare at all ages, and is almost 
never seen in infancy. Even though recovery from the attack takes place, 
complete restoration to health is very rare. 

The most frequent cause of death in acute cases is shock. Peritonitis 
is not found, at autopsy or operation so often as might be expected. In 
58 autopsies, it was seen but twenty times, and in seven of these it was 
limited to the intussusception. In but 7 cases was there perforation. In 
chronic cases death is usually from exhaustion or complications. 

Diagnosis. — This usually presents no difficulty in acute cases provided 
the physician has the condition in mind. The great majority of such 
cases present nearly all the classical symptoms — viz., sudden onset, re- 
curring colicky pains, frequent vomiting, bloody and mucous stools 
without faecal matter, general prostration or collapse, and low tempera- 
ture. The records show that the most common error is to regard the case 
for the first few days as one of gastro-enteritis or ileo-colitis, the physi- 
cian's attention being engrossed by the vomiting and bloody stools. Given 
the other usual symptoms, the presence of the characteristic tumour is 
conclusive evidence of intussusception. Unless the patient is very much 
relaxed, a satisfactory examination is possible only under full anaesthesia. 
In any case of acute obstruction in infants, intussusception should first be 
considered. Chronic cases present no diagnostic symptoms except the 
tumour. In both acute and chronic cases the rectal examination is most 
important for diagnosis, and often settles the question at once. 

Prognosis. — The prognosis of intussusception depends upon the age of 
the patient, upon the variety of the disease — whether acute, subacute, or 
chronic — and upon the time when proper treatment is begun. 

There were collected by Pilz * in 1870, 94 cases under one year, the 
mortality being 84 per cent. Of 135 cases of the same age reported be- 
tween 1870 and 1891 the mortality was 59 per cent. In Pilz's table, of .">1 
cases between one and ten years of age, the mortality was OS per cent ; 
while of 82 cases between one and ten years of age, from L873 to L891, 
the mortality was but 40 per cent. Formerly recovery was rare, except 
in cases of sloughing; but with earlier diagnosis and a better under- 
standing of the proper methods of treatment, the mortality has been rery 

*Jahrbuch fi'ir Kimlcrh., I'.d. iii, p. 6, 
31 



'otomy, 5 


total, 


21 cases 


2 


a 


17 " 


2; 


" 


5 " 


2; 


" 


13 " 


0; 


a 


1 case. 



3S6 DISEASES OF THE DIGESTIVE SYSTEM. 

much reduced. Combining the figures of Pilz with my own, there are 362 
cases with 231 deaths, or 63 -5 per cent. 

The following table shows the duration of the disease in 57 cases 
that were reduced either by injection or inflation, or which recovered 
after laparotomy : 

The Duration of Invagination in 57 Acute Cases which were reduced. 

Cured on 1st day by injection, 8 ; inflation, 

" 2d " 9; " 6: 

"3d " "3; " 0: 

" 4th " " 6; 5 

" 5th " " 1; 0: 

In two thirds of the cases, therefore, reduction was effected on the first or 
second day. After this time the chances of success are much reduced. 

Treatment. — In the management of a case of intussusception almost 
the same rules may be applied as in strangulated hernia — viz., first, a thor- 
ough attempt at reduction by mechanical means, with the assistance of 
taxis, and, this failing, an early resort to laparotomy. Only two methods 
of mechanical reduction can be relied upon, inflation and injections. 

Inflation should always be done under an anaesthetic, unless there is ex- 
treme relaxation. The position is not of great importance; preferably 
the child should lie upon the back, with thighs flexed. From time to 
time inversion may be practised, to get the assistance of traction of the 
intestine above upon the seat of invagination. An ordinary hand bellows 
with a catheter attached is the best apparatus for inflation. It should be 
done very slowly, and the air prevented from escaping by pressing the but- 
tocks tightly together. It is well to continue a gentle manipulation ot the 
tumour through the abdominal walls during inflation. The amount of air 
which it is safe to inject must be left to the judgment of the physician. 
The best guide to the amount which has been introduced is the tension 
of the abdominal walls. A thorough trial of this method should occupy 
from fifteen to thirty minutes. 

Reduction is sometimes indicated by rumbling sounds, and by the 
abdomen resuming its normal contour because the whole of the colon is 
filled, in place of the unequal distention before present. In several in- 
stances a distinct change in the expression of the features has been noted. 
In some cases a gush of fluid faeces has followed disinvagination. Not in- 
frequently all such decisive symptoms are absent, and the physician may 
be in doubt whether or not reduction has taken place. The air is al- 
lowed to escape, best by introducing the catheter high into the colon, so 
that careful palpation of the abdomen can be made while the patient is 
still under chloroform. The right iliac fossa should be examined with the 
greatest care, as it often happens that all the tumour except the last few 
inches has been reduced, this being impossible because of swelling. If the 



INTUSSUSCEPTION. 387 

examination is negative, the question of reduction must be decided by tbe 
general symptoms. If vomiting continues, if no gas or fasces pass the 
bowels, if there is no improvement in the pulse or the general condition, 
and, most of all, if the temperature rises, it is certain that reduction has 
not been effected, and a second attempt should be made. In a very acute 
case two or three hours' delay is all that should be permitted. Inflation 
may be repeated or an injection of water tried, but in either case consent 
to immediate laparotomy should be obtained if this effort does not suc- 
ceed. In cases not so acute, where three or four days have passed without 
symptoms indicating strangulation, it is admissible to make further at- 
tempts at reduction and delay laparotomy a little longer. 

Injections of fluids. — The patient is prepared as for inflation and the 
abdomen manipulated during the injection. Plain water may be used, a 
saline solution, milk and water, or thin gruel. The other substances 
possess some advantages over plain water in being rather less irritating. 
The temperature should be from 100° to 105° F. for the relaxing effect. 
The fluid is placed in a fountain syringe suspended four or five feet above 
the patient's bed. The injections should be made through a catheter, the 
escape of the fluid being prevented as in inflation. From time to time 
the flow of water should be interrupted, the pressure being maintained 
continuously. It may be desirable to increase the pressure by raising the 
syringe to the height of six or eight feet, but more is rarely advisable. 
The occurrence of reduction during injections is not usually quite so evi- 
dent as during inflation, and herein consists one of the advantages of the 
latter procedure. After from ten to twenty minutes the water is allowed 
to escape, and tbe abdomen examined. In making further attempts at 
reduction by injections one should be governed by the same considerations 
as in inflation. 

The choice between inflation and injection depends somewhat upon 
individual experience. My own preference is for inflation, mainly for the 
reasons given above, that it is easier to determine whether reduction has 
taken place both during and after its use. The danger of rupturing 
the intestine belongs alike to both ; but that it is not likely to occur 
in either is conclusively shown by the fact that in a series of 225 col- 
lected cases, all in children, and including nearly all those reported 
between 1870 and 1891, this accident has been recorded only once. In 
rare cases the symptoms may continue after reduction. Pick red 
a case in which laparotomy was done subsequently to inflation, with 
the belief that reduction had not been effected. No intussusception 
was found, and the continuance of the symptoms was attributed to 
paralysis. 

The treatment after reduction consists in keeping the patienl abso- 
lutely quiet and moderately under the influence of opium lor two or three 
days, to allay the excessive irritability of the intestinal walls. The diet 



388 DISEASES. OF THE DIGESTIVE SYSTEM. 

should be very light. Cathartics especially should be avoided for several 
days. 

Eecurrence of the invagination is not uncommon. It was noted in 
13, or about six per cent, of my collected cases under ten years ; of 
this number nine recovered and four died. Eecurrence is more likely to 
happen in the first twenty-four hours after reduction ; this was the time 
in nine of the thirteen cases. It may, however, be as late as a month, 
rarely later. In one half the cases there was but a single recurrence, but 
three, four, and even six recurrences in the course of a few weeks have 
been seen. Ludwig reports a case in an infant eight months old in whom 
twenty-two recurrences were seen in one month. This was of the colic 
variety ; it could hardly happen in any other form. 

Laparotomy is indicated as soon as a thorough trial of reduction by 
inflation or injection has been made without success. In the very acute 
cases the operation should not be delayed an hour after such failure is evi- 
dent. Needless delays have caused death in many instances. The opera- 
tion should not be looked upon as a last resort in hopeless cases, but as a 
measure which, if employed reasonably early, offers a fair prospect of suc- 
cess where disinvagination can not be accomplished by any other means. 
I have collected 72 cases in which the abdomen has been opened for the 
relief of intussusception in children. In 35 of these the operation was 
done at so late a period that reduction of the invagination was impos- 
sible owing to swelling, adhesions, gangrene, or other causes. In every 
instance the child died. In the 37 cases in which reduction was ef- 
fected at the operation, 14, or thirty-eight per cent, recovered. More 
than half the cases were under one year, and all but three were under 
two years, showing that early infancy is no barrier to the operation. In 
over one third of the cases the operation was done in the first twenty- 
four hours, and in half of them on the first or second day. The time of 
operation has therefore more to do with the result than any other factor. 
Of 16 operations in the first and second days there were 7 recoveries, or 
forty-four per cent. Of 44 operations on or after the third day there were 
7 recoveries, or sixteen per cent, and two of these were chronic cases. 

Summary. — Cathartics are absolutely contra-indicated in all circum- 
stances. Opium is to be administered as soon as the diagnosis is made, 
for the relief of pain and to prevent the increase of the intussusception, 
also in all cases after reduction by mechanical means or operation. Infla- 
tion and injection are to be tried successively, preferably under an anaes- 
thetic, combined with manipulation of the abdomen, sometimes with in- 
version of the patient. Not more than two trials should be made in acute 
cases. The abdomen should then be opened without an hour's unnecessary 
delay. 



APPENDICITIS. 389 



CHAPTER X. 

DISEASES OF THE INTESTINES.— {Continued.) 

APPENDICITIS. 

The terms typhlitis, perityphlitis, and perityphlitic abscess were for- 
merly much used to denote certain forms of inflammation occurring in 
the right iliac fossa. Of late these terms are but little employed, as it 
has been shown that these conditions are almost invariably due to disease 
of the vermiform appendix. The existence of typhlitis as a separate and 
independent disease is exceedingly rare, if indeed it ever occurs except as 
a result of faecal impaction. 

Inflammation of the appendix may be catarrhal, ulcerative, or perfora- 
tive, and it may be acute, chronic, or recurrent. 

Etiology. — The predominance of the male sex holds even in childhood. 
Of 101 collected cases under fifteen years, 72 were males and 29 females. 
This difference has never been satisfactorily explained. Appendicitis is 
exceedingly rare before the fourth year, but from this time it is of quite 
frequent occurrence throughout childhood, especially after the tenth year. 
Of 104 cases, 3 were under three years, 47 between the fourth and ninth 
years, and 54 between the tenth and fourteenth years. The youngest 
recorded case is in a child of seven weeks, reported by Demrae. The 
exciting cause is nearly always a foreign substance ; this is usually a faecal 
concretion, which is moulded by the appendix into the form of a date- 
stone, and often regarded as such. Small seeds, however, may form the 
nucleus of a faecal concretion, or less frequently they may be the only 
foreign bodv. In one of my own cases a pin was found in the appendix, 
and I have found references to two similar cases. Given the presence 
of a foreign substance, it is easy to see how inflammation may some- 
times be excited by a blow, fall, strain, or other slight accident. Chronic 
constipation is a factor of considerable importance. The micro-organism 
usually found in abscesses due to appendicitis is the bacterium coli com- 
mune, sometimes associated with other pyogenic germs, but very often in 
pure culture. 

Lesions.— The position of the appendix is extremely variable. It may 
be found in the pelvis, in the region of the kidney, and sometimes near 
the umbilicus. This anatomical peculiarity accounts for the variation 
seen in the situation of abscesses duo to appendicitis. According to 
Treves, the appendix is covered by peritonaeum at every point. 

Catarrhal appendicitis.— In this form there is thickening of the walls 
of the appendix from infiltration of its coats with cells. Its communication 



390 DISEASES OP THE DIGESTIVE SYSTEM. 

with, the caecum is temporarily or permanently shut off. The appendix 
is distended with mucus, pus, and usually some foreign substance, so 
that it may be as large as the thumb, or even larger. There is congestion 
of the peritoneal surface. This inflammation may subside without any 
serious consequence, or it may result in ulceration and perforation. These 
may follow the first attack, but more frequently not until several attacks 
have occurred. 

Ulcerative or perforative appendicitis. — Ulceration of the appendix 
may be found in cases of typhoid fever and in tuberculosis. In severe 
tuberculosis of the intestine I have nearly always found ulcers here. 
These ulcers rarely perforate, and as a rule they give rise to no clinical 
symptoms. 

The important form of ulceration is that due to an inflammation ex- 
cited by a foreign body, and this variety is apt to perforate. The inflam- 
mation may result in the gradual production of a small perforation by a 
process of ulceration, or the appendix may be distended by inflamma- 
tory products, and gangrene take place with the sudden production of 
a large opening. The nature of the perforation varies with the inten- 
sity of the preceding inflammation. The consequences will depend upon 
whether this occurs slowly or suddenly, and whether or not the ap- 
pendix is in such a situation that adhesions readily form. If ulceration 
takes place slowly, lymph is usually thrown out about the appendix, 
effectually protecting the general peritoneal cavity. If perforation occurs 
suddenly, the first effect is usually an intense congestion of the whole 
peritonaeum, and there may even be beginning inflammation. If the 
situation of the appendix is favourable for the production of adhesions, 
the inflammation in a very short time is limited by the plastic exuda- 
tion, and remains as a local peritonitis. If perforation in either of these 
varieties has carried infectious materials into the peritoneal cavity, there 
usually results a peritoneal abscess. If not, there is simply a localized 
plastic peritonitis with adhesions. I have said that these abscesses are 
in the peritoneal cavity. This is the view which is now almost uni- 
formly adopted, although it was formerly held that the abscesses were 
extra-peritoneal, being situated in the cellular tissue about the caecum 
(perityphlitic abscess). The situation of the abscess will depend upon 
the location of the appendix. It is usually in the iliac fossa, but may be 
in the lumbar region or in the pelvis. When left to itself it may open 
externally, or into any of the neighbouring viscera, usually the rectum ; 
or it may rupture into the general peritoneal cavity, setting. up a diffuse 
peritonitis. Earely, a large abscess may excite general peritonitis without 
rupture. If the appendix is so situated that adhesions can not readily 
form about it, or if these fail or are incomplete, sudden perforation of 
the appendix excites general peritonitis, usually of a septic variety, which 
runs a rapid and intense course. Among the secondary lesions which 



APPENDICITIS. 391 

have been met with in children, are suppurative pylephlebitis, abscesses of 
the liver, general pyaemia, empyema, and pneumonia. 

Symptoms. — Catarrhal appendicitis in many cases is not diagnosticated. 
Often, a positive diagnosis is impossible. The symptoms by which it is 
recognised are local pain, tenderness, and fever ; there may also be vomit- 
ing and constipation. Both pain and tenderness are moderate, but per- 
sist for several days. The tenderness is generally at McBurney's point. 
The elevation of temperature is usually slight, 100° to 101° F. These 
symptoms are often so mild that the child makes but few complaints, and 
is usually up and about. Very frequently they are passed over by young 
patients without any notice whatever, and recovery may take place with- 
out any diagnosis having been made. How frequently such cases occur 
we have no means of knowing positively, but they are undoubtedly much 
more common' than was formerly believed. 

Perforative appendicitis usually follows after several days the some- 
what indefinite symptoms of the catarrhal form, the patient perhajos having 
been hardly sick enough to go to bed. In rare cases the first symptoms 
may be those of perforation. These are usually severe and characteristic. 
There is sudden and intense pain in the right iliac fossa, accompanied by 
vomiting. The pain is acute, lancinating, and continuous ; the vomiting 
is repeated, sometimes being persistent ; it is first of the contents of the 
stomach and then bilious. Occasionally there is a chill. There is always 
much prostration, and the child from the outset has the appearance of 
being very seriously ill. With such an onset the disease may follow one 
of three courses, according as the perforation is followed by localized 
plastic peritonitis, localized suppurative peritonitis, or general peritonitis. 

1. With localized plastic peritonitis : The symptoms in these cases usu- 
allv last about a week. They are severe only for the first two or three 
days, and then gradually pass away. At the onset there are severe pain 
and tenderness, usually localized in the region of the appendix. There are 
vomiting, constipation, and slight fever, the temperature being from 100° 
to 102° F. The temperature gradually falls to normal; the tenderness 
becomes less acute ; and the somewhat diffuse infiltration in the iliac fossa, 
which was at first present, gradually lessens in area, until there is only a 
nodular tumour about the size of a hen's egg. This may be slow in dis- 
appearing, often lasting for weeks, and sometimes for months. These 
patients are always liable to recurrent attacks. 

2. With, localized suppurative peritonitis : In some of the cases with 
early symptoms like those above mentioned there is a continuance of the 
fever, pain, and tenderness, with the rapid format ion of an abscess. A 
distinct tumour may be noticed in the course of two or three days, and 
pus maybe found by aspiration or exploratory incision as the third 
or fourth day from the onset. At other times the earlv Like that 
of the cases which terminate in resolution, and marked improvement takes 



392 DISEASES OP THE DIGESTIVE SYSTEM. 

place after two or three days of severe symptoms. The temperature does 
not, however, quite reach the normal. After a variable period of quietude, 
lasting from two or three days to as many weeks, the temperature gradu- 
ally rises ; the pain and tenderness become more severe and are felt over 
a larger area ; the induration, which has been stationary, enlarges and be- 
comes more prominent, and the existence of abscess is unmistakable. In 
a small number of the cases terminating in abscess the onset is very grad- 
ual, without any of the acute symptoms mentioned. It may be accompa- 
nied by slight pain only, retraction of the right thigh, and moderate fever. 
Whether the formation of the abscess is rapid or slow, the subsequent- 
course may be the same. The sac is gradually distended with pus, which 
may accumulate in immense quantities ; as much as five pints have been 
evacuated. At the present time but few abscesses are allowed to open ex- 
ternally, incision being commonly made before that time. Large abscesses 
in the lumbar region or in the pelvis, may be mistaken for some other 
disease, or may be overlooked. Pelvic abscess may be easily recognised 
by rectal examination. The termination in a single abscess is a favourable 
one, for with proper surgical treatment these cases almost invariably 
recover. 

3. With general peritonitis : In these cases the early symptoms of pain, 
tenderness, vomiting, and fever are followed by those of general peritoni- 
tis. The vomiting continues ; the tenderness and pain are rapidly dif- 
fused over the abdomen ; there are constipation, tympanites, and very 
great prostration. The temperature is variable, and its height is no guide 
to the severity of the attack ; it usually ranges from 101° to 102-5° F., but 
may be normal or even subnormal. The general prostration is very great ; 
the pulse is rapid and feeble ; and in the worst. cases there are cold perspira- 
tion, hiccough, stercoraceous vomiting, collapse, and death. The duration 
of these cases may be but two or three days, but it is oftener from five 
to seven. The symptoms usually go on steadily from bad to worse. 
Sometimes, after the first intense onset, there may be a lull in the acute 
symptoms for a day or two, to be followed by a recurrence of the ago- 
nizing pain, vomiting, and collapse. Such symptoms indicate that the 
first perforation was followed by some limiting adhesions, which subse- 
quently gave way, causing all the symptoms of a new perforation. The 
symptoms of perforative peritonitis may come on late in the disease, when 
it is due to the rupture of an abscess into the peritoneal cavity. In a 
small number of cases the early symptoms of perforation are slight, or en- 
tirely wanting, the patient passing gradually into a state of great prostra- 
tion and profound sepsis, with the symptoms of general peritonitis. In a 
few cases general peritonitis complicates large abscesses without rupture. 
This termination is the most serious one, and is what occurs in nearly 
all the fatal cases. 

The frequency of the different varieties. — Of 98 cases in children 



APPENDICITIS. 393 

under fourteen years in which the exact variety was known, 10 termi- 
nated in resolution, 50 in abscess, and 38 in general peritonitis. These 
figures certainly do not represent the actual proportion terminating in 
resolution, for such cases are much more likely to be overlooked, or, if 
diagnosticated, they are not so commonly reported. Of the cases termi- 
nating in abscess, all but six were operated upon ; four of these opened 
into the rectum with a favourable result, one was allowed to open exter- 
nally, and one caused death by rupture into the peritonseum. From 
these statistics it would appear that general peritonitis is of more frequent 
occurrence in children than in adults. 

Prognosis. — Of 112 cases, there were 62 recoveries and 50 deaths — a 
mortality of 45 per cent. General peritonitis was the cause of death in 
eighty per cent, pyemia in eight per cent, all of them being protracted 
cases. The statement has been made (Matterstock, in Gerhardt's Hand- 
buch) that the majority of cases of peritonitis in children terminate fatally 
within the first three days. This is not borne out by my statistics. Of 43 
fatal cases, nearly all of them from general peritonitis, only 6 died during 
the first three days, 19 from the fourth to the seventh day, 13 in the second 
week, and 5 in the third week. Kecurrent attacks do not appear to be 
quite so common in children as in adults. They were noted in but two 
cases of this series. 

Cases terminating in the formation of a single abscess usually recover 
when properly treated. If general peritonitis occurs, whether early or 
late, the chances of recovery are small. In three cases recovery took 
place where general peritonitis was stated to be present at the time of 
operation. 

Diagnosis. — The diagnostic symptoms of appendicitis are a sudden 
severe pain in the right iliac fossa with localized tenderness and vomiting. 
Persistence of such tenderness is especially significant, as is also an un- 
natural resistance of the abdominal walls. Constipation is much more 
frequent than diarrhoea. There is usually some elevation of temperature, 
but rarely high fever. The catarrhal and perforative forms can not always 
be distinguished from each other. In some of the catarrhal cases the onset 
may be sudden and severe, while, on the other hand, perforation may take 
place without any of its characteristic symptoms. The exploring needle, 
it is now generally agreed, should be used only when a tumour is present. 

Appendicitis may be confounded with colic, indigestion, and, in infants, 
with intussusception; in older children, with abscesses due to psoitis. 
Colic is distinguished by the absence of localized tenderness and fever, by 
its short duration, and by the fact that the pain is generally less intense. 
Severe colic in older children Bhould, however, always be regarded with 
suspicion. From acute indigestion the diagnosis is often difficull at the 
onset, and it may be impossible for twenty-four hours. Very many of the 
cases of appendicitis have been regarded in the beginning as attack- of 



394 DISEASES OF THE DIGESTIVE SYSTEM. 

indigestion. Here, however, the pain is rarely so severe, but in children 
the fever is higher. The pain is not usually localized ; and, if so, it is more 
apt to be in the epigastrium or at the umbilicus. But it should be remem- 
bered that the pain is not always localized in appendicitis. The presence 
of pain, vomiting, and localized tenderness, and the greater severity of 
the constitutional symptoms, indicate appendicitis. Indigestion is more 
likely to be accompanied by diarrhoea than by constipation, while the 
opposite is true of appendicitis. 

I have twice known pneumonia at the right base to be mistaken for 
appendicitis. There was severe localized pain in the iliac fossa, which 
was evidently to be explained by pleurisy implicating the lower intercostal 
nerves. 

Intussusception, from its intense pain, colic, and vomiting, may sug- 
gest appendicitis, but it is very rare except in infants. Tenesmus and 
bloody stools are very constant ; the temperature is not elevated in the be- 
ginning ; if a tumour is present it is usually in the left side of the abdomen. 

Between the various forms of local suppuration in the right iliac fossa 
and appendicitis the diagnosis is rarely difficult. It should always be 
borne in mind that acute or subacute suppuration in this region is usually 
due to appendicitis. Abscesses, however, should not be confounded with 
those due to Pott's disease, or with a psoitis, which is, however, generally 
traumatic and accompanied by deformity due to the retraction of the 
thigh, which may be so severe as to lead to the diagnosis of hip disease. 
The constitutional symptoms of appendicitis are wanting. 

Treatment. — Absolute rest in bed should be insisted upon in every 
case, no matter how mild it may appear, and all patients should be closely 
watched. As a local application the ice-bag is to be preferred, unless 
strongly objected to by children, when hot fomentations should be sub- 
stituted. Morphine should be given in sufficient quantities to relieve 
pain, but the effect should not be carried further than this. An unneces- 
sary use of opium is objectionable, as obscuring important symptoms. The 
colon should be kept empty by the daily use of large enemata. All ca- 
thartics are to be avoided. Blisters, though formerly so much in vogue 
for the purpose of promoting resolution, with the better understanding of 
the nature of the disease, are now very seldom employed. 

Appendicitis is in the great majority of cases a surgical disease, and 
surgical advice should be sought early. It is undoubtedly true that in the 
past many lives have been needlessly sacrificed because surgical interfer- 
ence was too late resorted to. Operation is clearly indicated in two con- 
ditions : first, as soon as there is positive evidence of the existence of ab- 
scess ; secondly, when the symptoms point to perforation into the general 
peritoneal cavity. In such cases immediate operation should be done, 
as offering the only chance of recovery. Regarding other cases surgi- 
cal opinion is at the present time divided. One group of surgeons adviso 



INTESTINAL WORMS. 395 

exploratory incision in every case as soon as the symptoms are definite 
enough to indicate the existence of appendicitis, whether catarrhal or ul- 
cerative, with the hope of anticipating sudden perforation with its result- 
ing dangers. There is no doubt that by these surgeons a good many cases 
will be operated upon which might terminate in resolution. But it is 
claimed first, that the dangers of the operation per se are at the present 
time very slight, while in cases which resolve the danger of subsequent at- 
tacks is always present ; and secondly, that we have no means of knowing 
which of these cases may suddenly develop symptoms of perforative peri- 
tonitis. The other group of surgeons advocate deferring operation until 
there is evidence of the formation of pus, except when symptoms point to 
perforation into the general peritoneal cavity. It must remain for future 
experience to decide which of these two plans will receive the general 
sanction of the profession. Eegarding recurrent attacks of appendicitis 
opinion is also divided. For the details of the surgical management the 
reader is referred to surgical works. 



INTESTINAL WORMS. 

Judging by published reports, intestinal worms are much more com- 
mon in Europe than in this country. In 10,000 patients treated for med- 
ical diseases in my dispensary service, there was positive evidence of 
worms in but 79 cases. Of these, 9 had tapeworms, 40 roundworms, 27 
threadworms, and 3 both round and threadworms. In private practice 
among the better classes worms are certainly rare. I have not seen more 
than a dozen cases in ten years. 

Cestodes — Tapeworms. — Cestodes are usually introduced into the 
body by the ingestion of some form of food containing larvae (cysticerci). 
The larva of the tcenia solium is most frequently found in pork ; that of 
the tcenia mediocanellata in beef ; that of the bothriocephalus latus in 
fish ; that of the tcenia cucumerina inhabits dog or cat lice, being intro- 
duced into the intestinal tract accidentally by the hands. 

In the intestine the larvae develop into the mature tapeworms, usually 
in from three to three and a half months; after which the terminal seg- 
ments becoming mature, separate, and are discharged in the fasces, some- 
times singly, sometimes connected. New segments continually form next 
to the head as the terminal ones are cast off, so that the length of the 
worm is not diminished. The duration of life of the worm is estimated 
to be from ten to thirty years. Each mature segment is provided with 
both male and female sexual organs, and contains ova in great numbers. 
The ova escape after the rupture of the Begment outside the body. They 
find their way into the stomach usually of herbivorous animals with their 
food. Here the thick shells of the <>va are dissolved by fh< i gastric juice 
and the embryo set free. By means of the booklets with which il is pro- 



396 



DISEASES OF THE DIGESTIVE SYSTEM. 



vided, it migrates from the stomach or intestine and may be found in the 
muscles or in any organ of the body, even the brain and eye. When it 
reaches its final resting place it loses its hooks and gradually becomes 
transformed into a vesicle, from the inner surface of which there projects 
something resembling the head of the future tapeworm. In this stage it 
is known as the bladderworm or cysticercus. The cysticerci of the tcenia 
solium are sometimes found in man, but the other varieties very rarely. 
For the farther development of the larval form it must be taken into the 
stomach of man or some carnivorous animal. This occurs when pork, 
beef, or fish containing cysticerci is eaten. The vesicle wall is now dis- 
solved, and the head passing into the intestine develops into the mature 
tapeworm. Several varieties of taenia are found in the human intestine : 

Taenia Saginata or Mediocanellata — Beef Tapeworm (Fig. 63). This 
is the most frequent form found in children, all others being rare. In- 
fection results from eating raw or partially cooked beef containing cys- 
ticerci. The worm is from twelve to twenty feet in length, and has a 
square pigmented head without hooks but provided with four suckers. 
The full-sized segments are from one half to three fourths of an inch 
long and about half as wide. 

Taenia Solium — Pork Tapeworm (Fig. 64). This is a rare form in 
children, and comes from eating raw or partially cooked pork or sausage. 
It is from six to ten feet in length, the segments being nearly square. 





Fig. 63. — Taenia saginata; head, segment, 
and egg. (Jaksch.) 






Fig. 64. — Taenia solium ; head, segment, 
and egg. (Jaksch.) 



The head is about the size of a mustard seed and is pigmented. It also is 
provided with four suckers and a proboscis, surrounding which is a circle 
of about twenty-six hooks. 

Taenia Cucumerina or Elliptica (Fig. 65). The larvae of this form 
develop in a louse found on the skin of dogs and cats. Children who 
play with infected animals are the ones affected, the parasite being con- 
veyed to the mouth usually by means of the hands; it may thus be 
found even in young infants. Most of the tapeworms in infants are of 
this variety. This form of taenia is much smaller than either of the pre- 
ceding varieties, the full length being only from six to twelve inches. 



INTESTINAL WORMS. 



397 



Bothriocephalus Latus (Fig. 66). This is a rare form except in the 
sea countries of northern Europe and Switzerland, where it is said to be 





Fig. 



65. — Head and segment of taenia 
cucumerina. (Jaksch.) 



Fig. 66. — Bothriocephalus latus ; a, 5, front 
and side views of head ; c, segments ; 
d, eggs. (Jaksch.) 



very common. The larvae are harboured by certain fish, through which 
they are introduced into the body. The full-grown worm is from twenty- 
five to thirty feet in length. 

Taenia Nana and Taenia Flava Punctata. These are two rare varieties 
that have been found in children in a few instances. 

Usually but a single worm is present, although as many as five or six 
have been found. Earely taeniae have been associated with round and also 
with threadworms. 

Symptoms. — The only positive evidence of tapeworm is the discharge 
of the separated segments, either singly or in groups. Occasionally worms 
pass into the stomach and are vomited. Various abdominal symptoms 
may be associated with worms, but most of these are very indefinite in 
character and are more often due to other causes. The most frequent 
symptoms are bad breath, various annoying sensations, colicky attacks, in- 
ordinate or capricious appetite, and diarrhoea. Usually, if the patient is 
in good health, no constitutional symptoms are seen. Sometimes, particu- 
larly with the bothriocephalus latus, there is a very grave degree of anaemia. 
Many cases are now on record, some of them in children, in which the 
symptoms of pernicious anaemia have been present and have disappeared 
after the expulsion of the tapeworm. Nervous symptoms are not so often 
seen as with roundworms, and will be discussed in connection with them. 

Treatment. — Prophylaxis requires the cooking of meat to a sufficient 
degree to destroy the cysticerci. There is especial danger in eating raw- 
pork or sausage; that from rare beef is much less. The lis! of drugs 
used for the expulsion of the worm is a long one; probably the most sat- 
isfactory is the oleoresin of male fern, which should be given in capsule, 
in TTtxv doses to a child of fceu years, four capsules usually being adminis- 
tered at hourly intervals. The vermifuge should he preceded by several 
hours' fasting, and the bowels should be previously opened by a laxative. 



398 



DISEASES OF THE DIGESTIVE SYSTEM. 



The following plan of administration has been found satisfactory : A light 
supper of milk, and in the morning a saline laxative on rising, but no 
breakfast ; after the saline has acted freely the capsules are to be given, 
and following the last one, half an ounce of castor oil or some other active 
purge. Only milk should be given that day. The fragments passed 
should be carefully examined to see if the head has been expelled, as 
the worm is very likely to be broken at the neck. If this occurs it will 
grow again, and in about three months segments will appear in the stools. 
Other drugs useful for taenia are infusion of pomegranate root, turpentine, 
and chloroform. 

Nematodes. — Two varieties are found in the intestinal canal, the as- 
caris lumbricoides and the oxyuris vermicularis. 

Ascaris Lumbricoides — Roundworm. — This worm occupies the small 
intestine. It is much more frequently met with in children than the tape- 
worm. It is exceedingly rare in infancy, but 
is usually seen between the third and tenth 
year. In over one thousand autopsies upon 
infants I have only once found a roundworm 
in the intestine. 

The roundworm is from five to ten inches 
long, the female being longer than the male. 
It is of a light gray colour with a slightly 
pinkish tint, cylindrical, and tapering toward 
the extremities (Fig. 67). The eggs are oval 
in form, about ^-g- inch in diameter, and are 
numbered by millions. These worms rarely 
exist singly ; usually from two to ten are pres- 
ent, but there may be hundreds, and even 
thousands. When very numerous they coil up 
and form large masses, which may cause intes- 
tinal obstruction. • 

The life history of the roundworm is not 
yet perfectly understood. Epstein culti- 
vated outside of the body eggs taken from the stools, and found that 
under favourable conditions of sun and air five weeks were required for 
the development of the embryo. These were then fed to children. In 
three months the ova appeared in the stools, and after the administration 
of santonin many worms were discharged. From these experiments it 
would appear that no intermediate host is required, although this was pre- 
viously supposed to be the case. It was believed that the ova were swal- 
lowed by some worm or insect, and in this form were taken into the intes- 
tinal canal with green vegetables, fruit, or drinking water. 

The migration of these worms is curious, and in some instances truly 
remarkable. They frequently enter the stomach and are vomited. Occa- 




Fig. 67. — Ascaris lumbricoides; 
a, entire worm ; 6, head ; c, 
eggs. (Jaksch.) 



INTESTINAL WORMS. 399 

sionally one may appear in the nose. They have been known to pass 
through the Eustachian tube into the middle ear and to appear in the ex- 
ternal meatus. Entering the larynx they have produced fatal asphyxia. 
It is not very rare for them to enter the common bile duct and pro- 
duce jaundice. They may even enter in great numbers the smaller bile 
ducts and produce hepatic abscesses. They have been found in the pan- 
creatic duct, in the vermiform appendix, and in the splenic vein. It 
has long been known that they would perforate an intestine which was the 
seat of ulceration, but well-authenticated cases have been reported in which 
they have perforated an intestine previously healthy, setting up a fatal 
peritonitis. In Archambault's case they perforated the stomach. In cases 
of a persistent Meckel's diverticulum, worms have been discharged from an 
umbilical fistula. They have been found in umbilical abscesses. Consid- 
ering, however, the frequency of roundworms, migrations are rare. 

Symptoms. — The symptoms of roundworms are of the most indefinite 
kind. Often there are none until the worm is discovered in the stools. 
It is then fair to assume that others are also present. The most frequent 
abdominal symptoms are colic, tympanites, and other symptoms of indi- 
gestion, loss of appetite, restless, disturbed sleep, grinding of the teeth at 
night, and picking the nose. These symptoms are much more frequently 
due to other causes than to worms, but when all are present the existence 
of worms should be suspected. 

A great variety of nervous symptoms may be associated with intestinal 
worms. They are more often seen with lumbricoids than with either of 
the other varieties. The symptoms may be of the most puzzling character, 
and may simulate very closely those of serious organic disease. There 
may be chills, headache, vertigo, hallucinations, hysterical seizures, epi- 
leptiform attacks, convulsions, tetany, transient paralyses such as strabis- 
mus, and even hemiplegia and aphasia. All these have been observed 
in connection with intestinal worms, and from the fact that the symptoms 
disappeared completely after the worms were expelled there seems to be 
but little doubt that they were the cause of the symptoms. As in the case 
of the abdominal symptoms, however, intestinal worms are only one of the 
causes of such nervous disturbances, and certainly not the most frequent ; 
but the possibility that they may depend upon worms should not be 
overlooked. 

The only positive evidence of the existence of roundworms is {he dis- 
charge of a worm from the body, or the discovery of the ova in the Btools. 
A microscopic examination of the stools is a valuable means of diagnosis, 
and one that is too infrequently employed. When worms are present the 
ova may be found in great numbers. Their continued presence after the 
discharge of one worm, indicates that other worms remain. 

Treatment. — Altogether the most efficient agent for the removal of 
the worms is santonin. The same plan of administration may be [>A- 



400 



DISEASES OF THE DIGESTIVE SYSTEM. 



lowed as in the case of the tapeworm — viz., to give the drug on an empty 
stomach, preceded by a laxative. Santonin is best given in powdered 
form mixed with sugar. For a child of five years six grains are usually 
required. This amount should be given in three doses at intervals of four 
hours, followed by a purge of calomel or castor oil. 

Oxyuris Vermicularis — Pinworm — Threadworm. The oxyuris (Fig. 68) 
resembles a short piece of white thread. The female is about one third 
of an inch long, the male about one half that length, but is less frequently 
seen. The worm tapers toward the tail. The ova are of slightly irregular 
size, and are considerably smaller than those of the roundworm. 

The oxyuris inhabits chiefly the rectum and lower colon ; less fre- 
quently it may be found as high as the caecum. These worms have been 
seen in the stomach, and even in the mouth. If present they are usually 
discovered by separating the folds of the anus. The number of worms 

is usually large. The irrita- 
tion to which they give rise, 
causes a great production of mu- 
cus, and frequently leads to a 
chronic catarrh of the colon 
of considerable severity. The 
worms are imbedded in the mu- 
cus ; often they form with it 
small balls. According to Leuck- 
art, they are incapable of multi- 
plying in situ. For develop- 
ment, the ova must be swallowed 
by the patient or some other in- 
dividual. They as well as the 
worms are passed in enor- 
mous numbers with the stool. 
They attach themselves to the 
folds of the skin, the hairs about 
the anus, and even to the genitals. 
The patient may, through lack of cleanliness of the parts, continu- 
ally reinfect himself. After discharge from the body, the ova may be 
carried by flies and deposited upon fruits, vegetables, or in drinking 
water. 

Sijmjptoms. — The principal symptom caused by the oxyuris is itching 
of the anus or the genitals. This is caused by the migration of the 
worms from the bowel, and usually comes on at about the same hour at 
night, generally soon after the patient has retired. It is sometimes so 
intense as to be almost intolerable. It leads to frequent micturition, to 
incontinence of urine, in the male to balanitis, and in the female to vagi- 
nitis or vulvitis, and in both, but especially in the latter, it may be the cause 




I 



Fig. 68. — Pinworms. a, head ; b, female 
e, female and male, natural size: 
(Jakseh.) 



c, male 

d, ova, 



INTESTINAL WORMS. 401 

of masturbation. Owing to the catarrhal colitis which is excited, there is 
discharged a large quantity of mucus. The irritation may lead to pro- 
lapsus ani. Nervous symptoms are not so frequently associated as with 
the other varieties of worms, although I have seen at least one case of 
chorea in which they w r ere almost certainly the cause. They have been 
known to excite convulsions. 

Treatment. — This is usually spoken of as a very simple matter, and no 
doubt in recent cases, or where the number of worms is small, this is true ; 
but where the number is large, and considerable catarrhal inflammation of 
the colon is present, it is often a matter of the greatest difficulty to rid the 
bowel of these parasites. Cases often resist the most approved methods 
of treatment for months, even though carefully and thoroughly applied. 
The reason for this difficulty is, that the whole colon is doubtless infected, 
and that the upper part is very imperfectly reached by injections. While, 
therefore, injections are important and indeed invaluable, they can not 
be relied upon exclusively. The most scrupulous attention to cleanliness 
is an absolute necessity as the first step in the treatment of all cases. It 
is well to bathe the parts about the anus after each stool, and even two 
or three times a day, with a bichloride solution, 1 to 10,000. Itching is 
best controlled by the application of mercurial ointment to the folds of 
the anus at bedtime, this effectually preventing the escape of the worms 
from the bowel. The local application of cold will sometimes have the 
same effect. The most efficient of the injections is probably the bichlo- 
ride. The colon should first be thoroughly cleansed by an injection of 
lukewarm water containing one teaspoonful of borax to the pint, in order 
to remove the mucus. When this has been discharged, half a pint of the 
bichloride solution mentioned should be injected high into the bowel 
through a catheter, and retained as long as possible. This should be re- 
peated every second or third night. On other nights a simple saline 
injection may be employed. The infusion of quassia, asafoetida, aloes, 
and garlic are also useful. 

When the worms are high in the colon, drugs by the mouth must 
be combined with injections. The worms must be dislodged by the use of 
saline cathartics, and simple bitters, especially quassia and gentian, should 
be given by the mouth. I have known one case, which resisted for over 
two years everything which had been tried, cured in two or three weeks 
by injections of a decoction of garlic, in , connection with which garlic 
was given in large quantities by the mouth. 



32 



402 DISEASES OP THE DIGESTIVE SYSTEM. 



CHAPTER XI. 

DISEASES OF THE RECTUM. 

PROLAPSUS ANI. 

Under this term are included two conditions. In the first, or partial 
prolapse, there is simply an eversion of the mucous membrane which pro- 
trudes beyond the sphincter. In the second, or complete prolapse, there 
is invagination of the rectal wall for a variable distance, usually two or 
three inches. 

Etiology. — Prolapse is most common in children during the second 
and third years. Its frequency in early life is partly due to the lack of 
support furnished by the levator-ani muscles. It also occurs very readily 
when the ischio-rectal fat is scanty ; it is therefore often seen in children 
suffering from marasmus. The exciting cause may be anything which pro- 
vokes severe and prolonged straining. This may be either the tenesmus 
accompanying inflammation of the rectal mucous membrane or chronic 
constipation. It may come from phimosis or stricture of the urethra, and 
it is a very frequent symptom of stone in the bladder. 

Symptoms. — Prolapse usually occurs during the act of defecation. It 
is generally easily reduced, but shows a great disposition to return with 
every stool. In obstinate cases the bowel comes down at other times. 
The appearance of the tumour varies with its size. In the slighter form 
there is simply a ring composed of a fold of mucous membrane surround- 
ing the anus. In the more severe form there is a flattened, corrugated 
tumour, usually about the size of a small tomato (Fig. 69). The mucous 
membrane covering the tumour is of a deep purplish-red colour, and 
bleeds readily. It may be the seat of catarrhal or membranous inflamma- 
tion. The diagnosis in most cases is easy, although the tumour has been 
confounded with polypus and intussusception. 

Treatment. — In most cases reduction is easily accomplished by laying 
the child upon its face across the lap, and making gentle pressure upon the 
tumour with oiled fingers. The application of cold, either by means 
of ice or cold cloths, is of assistance in cases which are not at once reduced 
by pressure. After reduction, in the milder cases the child should be kept 
upon its back for at least an hour. Where the tumour tends to come 
down with every stool, special attention should be given at this time. If 
an infant, the bowels should always move while the child lies upon its 
back, and during defecation the buttocks should be pressed together by a 
nurse. Older children should use an inclined seat placed at an angle of 
about forty-five degrees, but should never sit upon a low chair or assume 



PROLAPSUS ANI. 403 

any position in which straining is easy. After defecation the patient 
should lie down for at least half an hour. "Where there is constipation, the 
bowels should be kept free by means of laxatives. If there is a diarrhoea, 




Fig. 69. — Prolapsus ani. 

tenesmus may be overcome by frequent sponging with ice water, or by 
the use of small injections of ice water and tannic acid, in the proportion 
of twenty grains to the ounce. In more severe cases it may be controlled 
by the use of suppositories of opium or cocaine. "Where the bowel tends 
to come down frequently, this may be prevented by the use of an adhesive 
strap two or three inches wide, placed tightly across the buttocks. This 
is better in the milder cases than a T-bandage. The great majority of the 
cases are cured by these means in the course of a few weeks. 

In the most severe cases the bowel not only protrudes during defeca- 
tion, but also in the interval, and it may be down for weeks at a time. 
Such cases are rarely seen except in infants who have very flabby muscles, 
and but little adipose tissue at the floor of the pelvis. Reduction is some- 
times difficult in cases where the prolapse has lasted a long time. It 
is often facilitated by painting the protruding part with a 4-per-cent solu- 
tion of cocaine, and then dilating the sphincter by passing the finger into 
the central openidg of the tumour. After reduction, suppositories con- 
taining from one fourth to one grain of cocaine may be inserted. They 
are more efficient than those containing opium or belladonna. A firm pad 
should be applied over the anus, held in position by a T-bandage. The 
tone of the levator and Bphincter-ani muscles is often greatly improved by 
local injections of strychnia. For a child two years old T , 1 ,„- grain may In- 
used twice a day. Where these measures fail, the protruding part may 
be touched with the Paquelin cautery, linear markings being made at in- 
tervals of an inch. Amputation or excision is not required in children. 



404 DISEASES OP THE DIGESTIVE SYSTEM. 

FISSURE OF THE ANUS. 

This is not a very uncommon condition in children. The most fre- 
quent cause is the passage of a large, hard, faecal mass. Sometimes it re- 
sults from traumatism inflicted with the nozzle of a syringe while giving 
an enema. It may be produced by the scratching excited by pinworms. In 
the beginning there is a simple tear at the margin of the anus. The 
laceration which is produced usually heals promptly ; but if the cause is 
repeated, healing is prevented, and there is finally produced a linear ulcer, 
or a true fissure, which may last for some time and be a source of great 
annoyance. 

A fresh fissure has the appearance of any other tear at a muco-cuta- 
neous orifice. One of longer standing has a gray base, slightly indurated 
edges, often discharges a small amount of pus, and bleeds a drop or two 
with nearly every movement of the bowels. The most constant symptom 
is pain, which usually occurs with the act of defecation, and continues for 
some time afterward. It is most severe when the fissure is just at the 
margin of the sphincter, and leads the child to resist every inclination to 
have the bowels move, so that it becomes a cause of chronic constipation, 
which condition again greatly aggravates the fissure. The pain is often 
referred to other parts in the neighbourhood. 

The treatment is simple and usually efficient. It consists in clean- 
liness, overcoming the constipation, and touching the fissure with nitrate 
of silver, preferably with the solid stick. The application should be re- 
peated every second or third day until the cure is complete. Stretching 
the sphincter may be necessary in very severe cases. 

PROCTITIS. 

Proctitis, or inflammation of the rectum, usually occurs with inflam- 
mation of the rest of the large intestine, but it may occur alone. It is 
to the cases in which only the rectum is involved that the term is gen- 
erally applied. 

The causes are for the most part local. A frequent one in infants 
is the use of irritating injections or suppositories, either for the relief of 
constipation or as a means of administering certain drugs. I have seen 
one obstinate case in an infant a year old, following the prolonged use of 
glycerin suppositories. It is sometimes caused by traumatism, especially 
by the careless giving of an enema. It accompanies pinworms. In 
certain cases it may result from direct infection through the anus. This 
may be from a gonorrheal inflammation extending from the vagina or 
urethra, or from an infection due to other bacteria, particularly in cases 
of measles, scarlet fever, and diphtheria ; or finally, it may be due to syph- 
ilis. The varieties of inflammation are the same as in the rest of the in- 
testine. Proctitis may thus be catarrhal, membranous, or ulcerative. 



PROCTITIS. 405 

Catarrhal Proctitis. — The pathological conditions are the same as in 
ordinary catarrhal inflammation of the intestinal mucous membrane. By 
the introduction of a speculum, or by simply everting the mucous mem- 
brane, it is seen to be reddened, swollen, and bleeds easily. There is a co- 
pious secretion of mucus. In cases of long standing there may be super- 
ficial ulceration appearing as a white or yellowish- white surface, usually 
just inside the sphincter. 

The symptoms are chiefly local, although a condition of general irrita- 
bility may result from the local condition. There is heightened reflex 
action, so that the stool often comes with a squirt. There is pain with 
defecation, and mucus is discharged, usually as a clear, jelly-like mass, 
and sometimes in the form of a cast, but not generally mixed with the 
stool. There are usually traces of blood, but rarely large haemorrhages. 
In the most acute cases, tenesmus is always present both during and after 
the stool. There may be prolapsus ani. The skin in the vicinity is irri- 
tated by the discharges, most frequently so in infants. If the cause is pin- 
worms, there may be intense itching. The duration of the disease is 
indefinite, depending upon the cause. It may be a few days or many 
months. The inflammation may extend from the rectum to neighbouring 
parts, leading to ischio-rectal abscess. 

Membranous Proctitis. — It has been customary to describe this as a 
complication of diphtheria, usually occurring with diphtheria of the exter- 
nal genitals. As very few of these cases have been studied bacteriolog- 
ically, it is impossible to say what proportion of them, if any, are to be 
regarded as true diphtheria. It is probable that the great majority are 
due to infection by streptococci. When the infection is from the intestine 
above, the rectum is never affected alone. When it is from below, this 
may be the case. The lesions are the same as in membranous inflamma- 
tion occurring higher in the colon. The symptoms resemble those of the 
catarrhal variety, with the addition that the stools contain patches of 
pseudo-membrane. This can be made out only by repeatedly washing the 
discharges with water. If accompanied by prolapse, the pseudo-membrane 
may be seen. Membranous proctitis may be complicated by a pseudo- 
membranous inflammation of the genitals or the perinaeum. Although 
it is usually acute, it may last for weeks. 

Ulcerative Proctitis. — Ulcers of the rectum may be the result of a ca- 
tarrhal inflammation; these, however, are usually superficial, affecting the 
mucous membrane only, and in most cases heal rapidly. Sometimes they 
extend more deeply into the submucous or even the muscular coat. They 
are then chronic, often very obstinate, and may last indefinitely. Follicu- 
lar ulcers of the rectum arc nearly always associated with the same con- 
dition in the sigmoid flexure. These are always multiple and usually 
small, rarely being more than a quarter of an inch in diameter. Some- 
times the small ones coalesce, producing much larger ulcers. Membranous 



406 DISEASES OF THE DIGESTIVE SYSTEM. 

proctitis is rarely followed by ulceration, although this is a possible result 
where sloughing has occurred. Single ulcers may be of tubercular origin. 
Steffen reports two cases of tubercular ulcer of the rectum in children of 
seven months and three years respectively. I have seen one in a young 
infant, which was fully three fourths of an inch in diameter, and w T as not 
associated with other tubercular disease of the large intestine. Syphilitic 
ulcers are extremely rare in children. 

The symptoms of ulcer of the rectum are mainly two — pain and haem- 
orrhage. The pain is of variable intensity, and may be referred to the 
coccyx, or to any of the neighbouring parts. The amount of bleeding 
may be small, the blood coming in clots, or it may be fluid and in so large 
a quantity as to produce general symptoms. It usually accompanies every 
stool. In addition the stool contains more or less pus, particularly in 
chronic cases. When the ulcer is low down, tenesmus is present and may 
be a prominent symptom. A positive diagnosis of ulcer can be made only 
by examination with a speculum. 

Treatment. — In cases of acute catarrhal proctitis injections of some 
bland fluid should be employed, such as a starchwater, limewater, a mixture 
of oil and limewater, or a warm one-per-cent saline solution. . The local 
cause, if one is present, should be removed. Where the stools are exceed- 
ingly acid, alkalies may be given by the mouth. The disordered digestion, 
when present, is to be treated according to its special symptoms. In the 
most acute cases the patient should be kept in bed. Where the tenesmus 
is severe, suppositories of opium or cocaine may be used. In the more 
chronic cases saline injections should be given, and followed by a mild 
astringent like tannic acid, ten grains to the ounce, or a one-per-cent solu- 
tion of hamamelis. Cases associated with pinworms are especially obsti- 
nate. Here the treatment is first to be directed to the worms, and after- 
ward to the proctitis. 

In the membranous cases the same measures are to be employed, and 
in addition the injection of a warm boric-acid solution two or three 
times a day. 

Cases of ulcer require the most careful treatment. In many there is 
but little tendency to spontaneous recovery. An examination with the 
speculum should be insisted upon in all cases of chronic proctitis, to 
make sure of the diagnosis. Rest in bed is essential to a rapid improve- 
ment. The patient should be put upon a bland diet, especially of milk, 
and the bowels kept freely open by the use of laxatives, and injections 
twice a day of a saturated boric-acid solution. Locally there should be 
applied a solution of nitrate of silver, one grain to the ounce, the bowel 
having previously been washed with tepid water. If a stronger solution 
than this is used, it should be neutralized after half a minute by the 
injection of a salt solution. 



HEMORRHOIDS. 407 

ISCHIO-RECTAL ABSCESS. 

This is not a very rare condition even in infancy. Infection from the 
rectum, usually through the lymph channels, seems to be the most com- 
mon cause, although sometimes the abscess may be traced directly to trau- 
matism. In a single year I have seen six cases. All but two were small, 
circumscribed abscesses and quite superficial, apparently starting as an 
acute inflammation of the lymph glands of the region. They are analo- 
gous to a similar process in the lymph glands of the neck, seen in in- 
fancy. These cases healed promptly after incision. In other instances 
there is seen a disposition to burrow, as in adults. Only once have I met 
with diffuse suppuration in the ischio-rectal region, terminating in slough- 
ing and death, and this was in an infant only three months old. 

Essentially the same varieties of inflammation are seen in early life as 
in adults. Most of these cases recover promptly after simple incision and 
cleanliness, fistula being a rare sequel. 

HEMORRHOIDS. 

These, fortunately, are not often seen in children, although they may 
occur even in those as young as three or four years. The principal cause is 
chronic constipation. The tumours are generally small and external, the 
chief symptom complained of being pain on defecation. Bleeding some- 
times accompanies the pain, but the haemorrhages are usually small. 
The treatment is to be directed toward the underlying cause. In most 
of the cases this suffices to cure the condition. I have never yet seen in 
a young child a case requiring operation, although neglect may make this 
procedure necessary. 

INCONTINENCE OF FECES. 

Inability to control the faecal evacuations is seen in certain cases of 
paraplegia due to myelitis, in injury of the lumbar portion of the spinal 
cord, and in spina bifida. It is also seen in the coma of meningitis, and 
occasionally in the typhoid condition and in extreme adynamia, no matter 
in the course of what diseases they develop. In all these conditions in- 
continence of faeces is a symptom giving rise to much annoyance and 
needing careful attention. Uncleanliness with reference to excreta, Been 
in idiocy, can hardly be elassed as incontinence. 

Besides these familiar forms, the condition is sometimes Been from 
causes somewhat resembling those of incontinence of urine. The tone 
of the sphincter becomes so feeble that it does not resist even the slightest 
impulse to evacuate the rectum. The discharge may take place with but 
little warning, and may occur either by day or night. In some cases a 
local cause exists, such as stretching of the sphincter by a rectal prolapse 



408 



DISEASES OF THE DIGESTIVE SYSTEM. 



or by impaction of faeces ; more frequently, however, the causes relate to 
the general nervous condition of the patient. Fowler * (New York) has 
reported two very typical cases of this variety, and I have seen one. They 
are, however, very rarely met with in practice. Of the cases reported in 
literature, the majority have occurred in highly nervous, anaemic children. 
Fowler's cases were cured by the use of ergot given by the mouth and by 
suppository. In cases not relieved by this treatment, strychnia should be 
injected locally as described under Prolapsus Ani. In all cases the gen- 
eral condition should receive careful attention. 



CHAPTEK XII. 
DISEASES OF THE LIVER. 

The liver is not often the seat of disease in infancy and early child- 
hood. Nearly all the forms seen in adult life are occasionally met with in 
later childhood, although even then they are quite rare. 

Size and Position. — The weight of the liver in the newly-born child, 
from one hundred and seven observations of Birch-Hirschfeld, is 4-5 ounces 
(127 grammes), or about 4*2 per cent of the body weight. The following 
table gives the results of one hundred and seventy-four observations upon 
the liver in infancy in the autopsy room of the New York Infant Asylum : 

Weight of the Liver in Infancy. 





AVERAGE. 


Per cent of 
body weight. 


Age. 


Ounces. 


Grammes. 


3 months 


6-3 

7-5 

11-0 

14-0 

160 


180 
212 
311 
397 
453 


31 


6 " 


3-0 


12 " 


3-40 


2 years 


3'3? 


3 " 


3-26 







In adults, according to Frerichs, the weight of the liver is about 2*5 
per cent of the weight of the body. 

The upper border of the liver is best made out by percussion. In the 
child, the upper limit of the liver dulness in the mammary line is found 
in the fifth intercostal space ; in the axillary line, in the seventh space ; 
posteriorly, in the ninth space. The lower border is best determined by 
palpation. This, as a rule, in the mammary line is found about one half 
an inch below the free border of the ribs. According to Steffen, the left 
lobe is relatively larger in the child than in the adult. The liver may be 



* American Journal of Obstetrics and Diseases of Children, October, 1882. 



FUNCTIONAL DISORDERS OF THE LIVER. 409 

displaced downward by contraction of the chest, as in rickets, or by an 
accumulation of fluid in the pleural cavity. It is frequently found lower 
than normal in conditions of great emaciation, owing to relaxation of the 
abdominal walls and its ligamentous supports. Upward displacement is 
much less frequent, and depends usually upon ascites or abdominal tumours. 

Malformations and Malpositions. — Congenital malformations relate 
chiefly to the bile ducts. These have been considered in the chapter de- 
voted to Icterus in the Newly-born (page 76). 

The liver may be found upon the left side in cases of general transpo- 
sition of the viscera. In fissure of the diaphragm it has been found in the 
thoracic cavity. 

ICTERUS. 

Icterus, or jaundice, occurs in children, as in adults, from two general 
classes of causes. The first includes those cases in which there is some 
obstruction of the flow of bile from the liver into the intestine, or obstruc- 
tive jaundice. In the second group, in which the jaundice is classed as 
non-obstructive, it depends upon certain changes in the blood itself. This 
is seen in the physiological jaundice of the newly-born, in that associated 
with septic conditions and as the result of certain poisons. 

Obstructive jaundice from pressure upon the bile ducts is extremely 
rare in children. Obstruction by a roundworm entering the common 
duct has been recorded, but is also very rare. The principal form of ob- 
structive jaundice seen in early life, is catarrhal. This has already been 
considered in connection with Gastro-duodenitis (page 297). 

FUNCTIONAL DISORDERS. 

Functional derangements of the liver are undoubtedly exceedingly com- 
mon in childhood. They are as yet but little understood, and it is almost 
impossible to separate them from the other symptoms of intestinal indiges- 
tion with which they are associated. These are described in the chapter 
upon Chronic Intestinal Indigestion. Some of these symptoms depend 
upon a diminution in the quantity, or the impoverished quality of the 
biliary secretion. There are gray or white stools, flatulence, and other evi- 
dences of increased intestinal putrefaction. These in all probability depend 
upon imperfect absorption in consequence of the absence of bile, rather 
than upon the absence of some antiseptic property, as recent experiments 
seem to show that the bile is not an intestinal antiseptic. The other 
functional disturbances of the liver relate to its effecl nppn the proteid 
substances which undergo destructive metamorphosis in this organ. The 
nature of this change, and the symptoms which result from this disturbance 
are as yet but imperfectly understood. It is quite probable that many of 
the nervous functional disorders of children — for example, attacks of 
migraine or of cyclic vomiting — may depend upon such a cat 



410 DISEASES OF THE DIGESTIVE SYSTEM. 

ACUTE YELLOW ATROPHY. 

This form of hepatic disease, although rare in adults, is still more rare 
in children. Greves* has reported a well-marked case in an infant of 
twenty months, and has collected seventeen other cases under ten years of 
age ; the youngest was in an infant three months old. The causes are 
obscure. The symptoms and course of the disease are essentially the 
same as in adults. 

CONGESTION OF THE LIVER. 

This occurs from the same cause as in adults. Acute congestion is not 
often seen. It may result from a malarial fever and from certain poisons, 
particularly phosphorus. Chronic congestion is more common, and is usu- 
ally secondary to general venous obstruction dependent upon congenital 
or acquired heart disease, atelectasis, or other pulmonary conditions, par- 
ticularly chronic pleurisy, chronic interstitial pneumonia, and emphysema. 
Chronic congestion of the liver causes no characteristic symptoms except a 
moderate enlargement of the organ. The disturbance of its functions is 
not of such a nature as to be diagnostic. In acute congestion, there may 
be in addition to the swelling of the liver, some localized pain or tender- 
ness. The treatment is that of the original disease upon which the con- 
gestion depends. 

ABSCESS OF THE LIVER— SUPPURATIVE HEPATITIS. 

In 1890 Musser f found but thirty-four recorded cases of abscess under 
thirteen years. Since that time a few additional cases have been reported. 
This suffices to show how rare the disease is in early life. In the above 
collection, there have not been included cases of suppurative hepatitis oc- 
curring in the newly-born. 

As in adults, abscess of the liver may result from traumatism, or it 
may be secondary to suppurative pylephlebitis, which depends upon a 
focus of infection in the umbilical vein, or in some part of the abdomen 
from which the branches of the portal vein arise. Pylephlebitis may fol- 
low appendicitis (Bernard's case), it may follow typhoid fever directly 
(Asch's case), or be due to suppuration of the mesenteric glands or peri- 
tonitis following typhoid. In seven of the cases collected by Musser 
the disease was due to migration of roundworms from the intestine into 
the hepatic ducts. Menger (Texas) has reported one case following dysen- 
tery, the only one, I think, on record in this country. In quite a number 
of cases no adequate cause can be found. A striking example of this was 

* Liverpool Medico-Chirurgical Journal, July, 1884. 
f Keating's Cyclopaedia, vol. iii, p. 466. 



ABSCESS OF THE LIVER. 411 

reported to the New York Pathological Society by Swift, in 1882, where 
an abscess occupying nearly the whole right lobe occurred in a child 
three years old. 

In the cases occurring in pyaemia and in those associated with pyle- 
phlebitis there are usually several abscesses ; in traumatic cases generally but 
one. The abscesses of early life do not differ very much from those of 
adults. If untreated, the majority of cases prove fatal either from exhaus- 
tion or from rupture into the pleura or peritonaeum. In Asch's case spon- 
taneous cure took place by rupture into the intestine. 

Symptoms. — Occasionally abscess in the liver is latent, but in most of 
the cases the symptoms are marked and sufficiently characteristic to make 
the diagnosis a matter of no great difficulty. The most constant general 
symptoms are chills, which may be single, but are usually repeated ; fever, 
which is commonly of the hectic variety and followed by sweating ; pros- 
tration, vomiting, diarrhoea, and cachexia. Jaundice is present in less than 
half the cases, and is rarely intense. The liver is almost invariably suffi- 
ciently enlarged to be easily made out by palpation or by percussion ; the 
enlargement in most cases is chiefly downward. Tumours on the surface 
of the liver are often present ; these may be recognised as abscesses by the 
presence of fluctuation. Pain is quite constant, and frequently intense, 
but not always in the region of the liver. It may be in the epigastrium, 
at the umbilicus, in the lower part of the abdomen, and occasionally 
in the right shoulder. Tenderness over the liver is usually present. A 
positive diagnosis of hepatic abscess is to be made only by aspiration and 
the withdrawal of a fluid having the characteristics known as "liver 
pus." Pulmonary symptoms usually exist with an abscess occupying the 
convexity of the right lobe. There may be cough and dyspnoea from 
pressure, or pleurisy from extension of the inflammation through the 
diaphragm, or from rupture into the pleural cavity. The usual duration 
of abscess of the liver after the beginning of the symptoms is from one to 
two months. The prognosis will depend upon the cause of the disease. 
The pyaemic cases are usually fatal. In Musser's collection, the proportion 
of recoveries was about thirty per cent. At the present time, witli im- 
proved methods of treatment and earlier diagnosis, the outlook is some- 
•wliat better than this. 

Treatment. — This is purely surgical. Without operation the chances 
of recovery are very slight. A small number of cases have been cured 
by aspiration, but in the vast majority only incision and drainage are to 
be depended upon, and, if the abscess is accessible, should be resorted to 
as soon as the diagnosis is established. 

CIRRHOSIS. 

This is exceedingly rare in early life, although quite a number of cases 
are now on record between the ages of seven and fourteen years. Sixty- 



412 DISEASES OF THE DIGESTIVE SYSTEM. 

five have been collected by Howard* and fifty-three by Laure and 
Honorat.f Nearly all the cases in these collections were between nine 
and fifteen years. Cirrhosis in infancy is usually of syphilitic origin. 
Two thirds of those in Howard's collection were males. The etiology in 
most of the cases is obscure ; in over half of those reported no cause could 
be discovered. Fifteen per cent of Howard's cases were traced to alco- 
holism, eleven per cent to syphilis, and eleven per cent to tuberculosis. 
Laure and Honorat believe that the eruptive fevers sometimes play an 
important part as an etiological factor, and that at other times the cause 
is possibly malaria. 

The anatomical features of cirrhosis in early life are essentially the 
same as in adults. The liver is sometimes enlarged, but usually it is 
smaller than normal. The connective tissue may be distributed around 
the lobules, along the bile ducts, in irregular patches, or in striations 
through the organ. Associated with this there are atrophy and fatty de- 
generation of the liver cells. In some of the cases reported there has 
been also a similar increase in the connective tissue of the spleen and 
kidneys. 

Symptoms. — These are very much the same as in adult life. In the 
beginning there are the indefinite disturbances referable to the digestive 
organs, and the liver may be found to be slightly enlarged ; later there are 
ascites, enlargement of the spleen, and dilatation of the abdominal veins. 
Ascites is a pretty constant symptom, and is generally marked. Slight 
icterus is often present, but a marked amount is rare. There may be 
haemorrhages from the stomach, from the nose, or from other organs ; in a 
few cases there is slight fever. The late symptoms are a small liver, 
marked ascites with the consequent embarrassment of respiration, ca- 
chexia, and sometimes general dropsy. Diarrhoea is a much more constant 
symptom than in adults. Death usually takes place from exhaustion. 
The course of cirrhosis in children is commonly more rapid than in 
adults, and the progress is steadily downward. 

Treatment. — Medicinal treatment is of avail only in cases which are 
syphilitic. These should be put upon mercury and large doses of the 
iodides. The treatment in other respects is symptomatic and palliative. 
As largely as possible patients should be kept upon a milk diet. The 
ascites may require aspiration or puncture, as in adults. 

AMYLOID DEGENERATION (WAXY, LARDACEOUS LIVER). 

This condition results from prolonged suppuration in connection with 
chronic bone and joint disease, especially of the hip, knee, or spine. 
More rarely it is seen with chronic empyema, tuberculosis, or hereditary 

* American Journal of the Medical Sciences, 1887, p. 350. 

f Revue Mensuelle des Maladies de l'Enfance, 1887, p. 97, 159. 



FATTY LIVER. 413 

syphilis. Amyloid degeneration of the liver is associated with similar 
changes in the spleen and kidneys, and sometimes in the villi of the small 
intestine. 

The 4 liver is generally very much enlarged ; in extreme cases a weight 
of six or seven pounds may be reached. It is of a glistening, waxy colour, 
very firm and hard. With a solution of iodine, a mahogany-brown reac- 
tion is obtained. The amyloid degeneration affects first the arterioles, and 
finally the hepatic cells. 

Amyloid liver per se produces few symptoms. Ascites is rarely pres- 
ent except in cases in which the liver is very large, and jaundice does not 
occur. In addition to the symptoms of the original disease in the course 
of which the amyloid degeneration occurs, there is the peculiar waxy 
cachexia which is seen in no other condition, but resembles somewhat 
that belonging to malignant disease. The face has the appearance of ala- 
baster, and the skin has a singular translucency. The liver may be so 
large as to form a tumour, sometimes nearly filling the abdominal cavity. 
Not infrequently it extends to the umbilicus, and even to the crest of the 
ilium. The surface is smooth and hard, and the edges usually sharp. 
There is no localized pain or tenderness. The spleen is invariably en- 
larged. As a result of the amyloid degeneration of the kidney, there may 
be dropsy and albuminuria. Dropsy may occur from pressure of the large 
liver upon the vena cava, apart from the condition of the kidney. So 
many complicating conditions are usually present that it is almost im- 
possible to say which of the other symptoms are due to the changes in the 
liver. 

Amyloid changes take place slowly, the whole course of the disease 
being marked by years, the patient dying from slow asthenia, from ne- 
phritis, or from some acute intercurrent disease. As a rule, cases go on 
steadily from bad to worse ; but sometimes, after the disease has reached 
a certain point, the condition is stationary for a long time. 

The prognosis is always bad, although in a few cases improvement, 
and even cure, are stated to have occurred after the excision of the diseased 
joints upon which the amyloid degeneration depended. This, however, 
is a result which is not often met with. In cases of amyloid degeneration 
dependent upon syphilis, the usual anti-syphilitic remedies should be given. 
In other cases, no treatment is of any avail except that directed toward the 
removal of the cause. 

FATTY LIVER. 

This consists in an accumulation of fat in the liver cells. Ii is gener- 
ally a secondary condition in childhood, and causes no symptoms by which 
it can be positively recognised. 

Fatty liver is found at autopsy chiefly in children dying of marasmus, 
general tuberculosis, and in the other varieties of wasting disease, especially 



414 DISEASES OF THE DIGESTIVE SYSTEM. 

those associated with the digestive tract. In such patients it is par- 
ticularly common, but under other conditions it is quite rare. It is 
found in children of all ages, being frequent in infants. 

The liver is moderately enlarged, smooth, with rounded edges, of a 
yellowish-red or a lemon-yellow colour, and can be indented with the 
finger. A warm knife becomes coated with oil after cutting. Microscopic- 
ally there is seen an accumulation of fat in the liver cells, usually irregu- 
larly distributed. 

Jaundice, ascites, and the other peculiar symptoms of hepatic disease, 
are absent. The liver is moderately increased in size and its functions are 
interfered with, but not in such a way as to be recognised by the symptoms. 

The treatment is that of the original disease. 

HYDATIDS. 

Echinococcus disease of the liver, while rare among adults in this 
country, is almost unknown in children. I have been able to find but two 
recorded cases in America. 

From twenty-two European cases collected by Pontou (Paris, 1867), 
it appears that unilocular cysts are especially frequent in young subjects. 
The disease may be latent for months or years. The earliest symptoms 
are localized pain, jaundice, and occasionally fever. Later there is en- 
largement of the liver, particularly of the right lobe. If the upper surface 
is affected, pulmonary symptoms, cough and dyspnoea, are usually present ; 
if the under surface of the organ, there is pressure upon the portal vein, 
the vena cava, bile ducts, stomach, and intestines. This pressure may 
cause icterus, dilatation of the superficial abdominal veins, and sometimes 
ascites. The local signs are enlargement of the liver with a tumour, 
which is easily recognised in children because of the thin abdominal 
walls. The hydatid fremitus is usually obtained. By aspiration a clear 
fluid is withdrawn, showing under the microscope the presence of the 
hooklets, which establishes the diagnosis. Occasionally cure may take 
place by spontaneous rupture or suppuration of the cyst, but in most 
cases, when left to itself, the disease proves fatal. The treatment is surgi- 
cal, and consists in aspiration or in incision, and the evacuation of the cyst 

BILIARY CALCULI. 

Up to the age of puberty calculi are extremely rare. Walker* has 
reported a case in a child dying at three months, who had symptoms from 
the age of one month. Parrot has put on record one case in an infant 
twelve days old. Frerichs records one in a child of seven, and Simon one 
at six years. In the cases reported the symptoms have been like those of 
adults — colic and icterus, and finally the passage of the stone by the bowels. 

* British Medical Journal, 1882. 



ACUTE PERITONITIS. 



415 



CHAPTER XIII. 
DISEASES OF .THE PERITONAEUM. 

Inflammation of the peritonaeum is not very frequent in childhood, 
because at this time most of the causes which are operative in later life 
either do not exist at all or are very infrequent. An analysis of 187 col- 
lected cases of peritonitis — not including those associated with appendi- 
citis — gave the following results, which are of some interest as showing 
the relative frequency of the different forms in early life : 





Acute. 


Chronic. 


Total. 


Fibrinous 


22 
22 

46 
18 


10 
15 
16 
38 


32 


Serous 


37 
62 


Purulent 


Tubercular 


56 


Total 


108 


79 


187 



We shall consider separately acute, chronic, and tubercular peritonitis. 



ACUTE PERITONITIS. 

Acute peritonitis may occur at any period of infancy or childhood. 
It may even exist in intra-uterine life. In the newly-born, peritonitis is 
quite frequent. After this time it is exceedingly rare during infancy, only 
four cases, including all varieties, being met with in 726 consecutive au- 
topsies in the New York Infant Asylum. After the fifth year the dis- 
ease is relatively much more common. Of the 187 cases above referred 
to, 25 per cent occurred in the newly-born, 21 per cent between one and 
five years, and 54 per cent between the fifth and the sixteenth years. 

Etiology. — In the newly-born, peritonitis is seen as one of the most 
frequent lesions of acute pyogenic infection (page 81). It is usually duo 
to direct infection through the umbilical vessels. In infancy and child- 
hood, peritonitis occurs both as a primary and secondary inflammation. 
The primary form is rare. It may be due to traumatism, such as falls or 
blows, or to surgical operations upon the abdomen ; it has occurred after 
an injection for the cure of a congenital hydrocele. In a very small 
number of cases the inflammation Be erne to have been excited 1»\ cold 
or exposure, and it may follow severe burns. 

The secondary form is more common. The most frequent of all 
causes is appendicitis. These cases are, however, considered separatelj 
elsewhere. Extension of inflammation from the viscera to the peritonaeum 
is very much less frequent in children than in adults. It was mej with hut 
once in my autopsies (about 130 in number) in acute intestinal diseases. 



416 DISEASES OP THE DIGESTIVE SYSTEM. 

It is also rare in typhoid fever, being noted but twice among my 
collected cases. It is occasionally due to abscess of the liver, ulcer of 
the stomach, acute intestinal obstruction from internal strangulation, 
intussusception, volvulus, or congenital atresia. It may extend from in- 
flammation of the pleura. This may be in the form of empyema which 
burrows through the diaphragm, or, without burrowing, the infection 
may take place through the lymph channels. It is not very infre- 
quently due to infection through the female genital tract, especially in 
gonorrhceal vulvo-vaginitis in young girls. Extension of inflammation 
from the male genital organs is not common. In one case at the New 
York Infant Asylum, fatal peritonitis in an infant originated in a sup- 
purative inflammation of the tunica vaginalis of unknown origin, the 
infection extending into the peritonaeum through the inguinal canal. 
Any abscess in the neighbourhood may rupture into the peritonaeum 
and excite peritonitis. The most frequent in children are those con- 
nected with Pott's disease, perinephritis, and cellulitis of the abdominal 
wall. 

Of the acute infectious diseases, peritonitis is most frequently seen w r ith 
pneumonia and scarlet fever. In four cases occurring in the New York 
Infant Asylum the disease was twice secondary to pneumonia, in both 
complicated by extensive pleurisy. It may be accompanied by pericar- 
ditis, and even by meningitis. 

The bacteria most frequently associated with acute peritonitis in chil- 
dren are : the streptococcus, especially in the newly-born ; the micrococcus 
lanceolatus (pneumococcus), in cases complicating pneumonia or empy- 
ema ; and the bacterium coli commune in those following intestinal per- 
foration. These may be associated with other pyogenic bacteria, or less 
frequently the latter may occur alone. 

Lesions. — In the fibrinous form we have changes similar to those oc- 
curring in inflammation of the pleura and the other serous membranes. 
The peritonaeum is injected and lymph is thrown out in considerable quan- 
tity, usually accompanied by a small amount of serum. The process may 
be localized or general. It is more frequently general in the child than in 
the adult. The peritonaeum lining the abdominal wall, as well as that 
covering the coils of intestine and the solid viscera, is covered by patches 
of yellowish-gray lymph, causing adhesions between the various viscera 
and often matting the intestines together. In recent cases these adhesions 
are soft, and easily broken down ; in old cases they are quite firm, and 
they may result in the formation of connective-tissue bands which are the 
source of subsequent trouble. 

In the serous form there is a moderate amount of lymph, generally 
less than in the plastic variety, and, in addition, an outpouring of serum 
in considerable quantity. This is usually clear, but may be turbid from 
flakes of lymph, or it may even be bloody. In most cases the amount is 



ACUTE PERITONITIS. 417 

not very large, usually varying from half a pint to two pints. In cases 
going on to recovery the serum is absorbed, but there may result adhe- 
sions as in the preceding variety. 

In the purulent form the products are serum, lymph, and pus. When 
peritonitis results from perforation it is, as a rule, purulent from the outset, 
and the pus is foul and stinking. The amount of pus is generally larger 
than in adult cases. When the disease proves fatal in a few days there is 
found an extensive exudation of plastic lymph, with the formation of small 
pockets containing pus among the coils of intestine. Occasionally there 
may be larger collections of pus in the peritoneal cavity. In cases which 
have lasted a longer time — generally those of localized inflammation — the 
process results in the formation of a peritoneal abscess. This consists in 
a collection of pus in some part of the peritoneal cavity, the situation de- 
pending upon the cause, but it is usually in one iliac fossa or in the pelvis. 
The abscess is shut off from the rest of the peritoneal cavity by a thick 
wall of fibrin. If left alone, such abscesses may open into the rectum, 
vagina, bladder, pelvis of the kidney, or externally, usually at the umbili- 
cus. After the discharge of pus the cavity may contract and fill up by 
granulations, and the patient recover. 

Inflammations of the other serous membranes, especially the pleura, are 
often associated with peritonitis. 

Symptoms. — The symptoms of acute peritonitis in older children, as in 
adults, are usually well marked and sufficiently characteristic to enable 
one to recognise the disease easily ; but not so in the case of infants. In 
them the symptoms are often obscure, and the disease may be found at 
autopsy when not suspected during life. The onset is nearly always 
abrupt, with fever and vomiting. As a rule, the temperature is high — 
from 103° to 105° F. Vomiting may be only at the onset, but it often 
continues throughout the disease. Older children complain of pain, 
which may be localized or general ; and in younger ones this is indicated 
by restlessness, crying, and fretfulness. The abdomen very soon becomes 
swollen and tympanitic, this being one of the most constant features 
of the disease. The distention is generally uniform, but it may be irregu- 
lar. It is very rare in acute cases that there is a sufficient amount of fluid 
present to give the sensation of fluctuation. There are tenderness on pres- 
sure, and usually marked rigidity of the abdominal walls. The position 
assumed by the patient is generally dorsal, with the thighs flexed. The 
bowels are in most cases constipated, but diarrhoea is by no means rate. 
The abdominal distention causes dyspnoea and thoracic breathing. There 
may be retention of urine or freqnenl micturition. 

The general symptoms almost from the beginning, arc those of a seri- 
ous disease. The pulse is 8m all, rapid, and compressible. The prostra- 
tion is great, from the very outset. The face is pinched, the mouth is 
drawn, and the features indicate pain. In bad eases there may 1"' hi(S 
33 



418 DISEASES OF THE DIGESTIVE SYSTEM. 

cough, cold extremities, clammy perspiration, and collapse. The mind is 
usually clear. 

In the most severe forms of general peritonitis the course is short and 
intense, and the disease goes on rapidly from bad to worse until death 
occurs. In infants this is often on the second or third day. The most 
severe forms of general peritonitis in older children run the same rapid 
course. In other cases the course is slower, lasting a week or ten days. 
If the patient lives longer than this the case is more hopeful, because the 
process is more apt to be localized. The development of peritoneal ab- 
scess is indicated by the continuance of the temperature, which may 
assume a hectic type, and be accompanied by chills and sweating. There 
are the local signs of an abdominal tumour. 

Prognosis. — Acute general peritonitis, whatever its cause, is a very seri- 
ous disease in childhood. Of eighty cases of all varieties under sixteen 
years of age, sixty-nine per cent died. In the newly-born and in infancy 
the disease is almost invariably fatal. In older children the outlook is not 
quite so hopeless, and depends upon the exciting cause. It is better in 
localized than in general inflammation ; also in the fibrinous than in 
the purulent form ; but the most favourable cases are those with a sero- 
fibrinous exudation. 

Treatment. — The treatment of acute peritonitis in infancy and young 
children is very unsatisfactory, since it is almost invariably fatal. In 
older children it is to be conducted along the same general lines as in 
adults. For a local application, cold is usually to be preferred if it is well 
borne. It may be applied either by an ice-bag or by Leiter's coil. Many 
children, however, rebel against cold applications, and for them heat must 
be substituted. The most satisfactory way of applying heat is by spongio- 
piline, which is wrung out of very hot water and applied over the whole 
abdomen. It may be sprinkled with spirits of turpentine if counter-irri- 
tation is desired, or a light poultice may be used. Feeding and stimulation 
are especially difficult on account of vomiting. The diet should be milk 
whenever this can be retained, which preferably should be peptonized. 
Kumyss may be tried when milk is rejected. Brandy with ice may be 
used as a stimulant, or, if this is vomited, champagne. No effort should 
be made to overcome the constipation except at the very outset, when 
a saline cathartic may possibly be admissible, but never at a later period. 
The treatment by opium is the only one upon which any dependence can 
be placed as influencing the disease. This is preferably given hypoder- 
mically, on account of the vomiting. The dose must be regulated by the 
condition of the patient. Enough should be administered to control pain 
and peristalsis. The amount required must be determined by the condi- 
tions in each case. An initial hypodermic dose of morphine for a child of 
five years should be from -fa to -£% grain. This will ordinarily need to be 
repeated every two or three hours. There is great tolerance of opium in 



CHRONIC PERITONITIS. 419 

cases of peritonitis, but there is no advantage in pushing the drug further 
than is required to relieve the symptoms mentioned. There are com- 
paratively few cases in children in which the question of operation arises 
during the acute stage, except in those depending upon appendicitis. The 
cases of acute perforative peritonitis are almost certain to die under any 
treatment. Surgical interference is always indicated in peritoneal abscesses 
which have passed the active stage. These should be opened and drained 
in accordance with general surgical principles. Aspiration is not to be 
depended upon, and should be used only as a means of diagnosis. 

CHRONIC (NON-TUBERCULAR) PERITONITIS. 

Peritonitis may occur in foetal life with the production of extensive 
adhesions, which may interfere with the development of the intestine and 
result in various malformations. These cases have been ascribed by Sil- 
bermann * to syphilis. 

Chronic peritonitis may follow the acute form, in which there are left 
adhesions which slowly increase owing to the production of new connect- 
ive tissue. Such cases are sometimes chronic from the beginning. 

The peritoneal abscesses which follow the suppurative form may run a 
chronic course. Chronic localized peritonitis may occur in connection 
with disease of any of the organs covered by the peritonaeum. This is 
most commonly with the spleen, liver, and kidney. 

Chronic Peritonitis with Ascites. — In most cases this is chronic from 
the outset and independent of the above causes. By far the most frequent 
form of inflammation is that due to tuberculosis, and by some writers the 
opinion is still held that this form is always tubercular. After the obser- 
vations reported by Henoch, Vierordt, Fiedler, and others, there seems to 
be no longer any room for doubt regarding the existence of a chronic non- 
tubercular form of peritonitis with ascites, although it must be considered 
a rare disease. In its pathological and clinical aspects it is to be compared 
to subacute or chronic pleurisy with effusion. 

Etiology. — Nearly all the cases thus far reported have occurred in 
children over six years. The causes are for the most part obscure. The 
disease has been attributed to exposure, rheumatism, and injury. In 
a few instances it has followed measles. It may be associated with disease 
of the intestines or the solid viscera of the abdomen, especially with new 
growths of the kidney, liver, etc. 

Lesions. — The post-mortem observations thus far have been few. In 
the reported cases there has been found a large amount of greenish scrum 
in the general peritoneal cavity, with a very moderate amount of fibrin and 
adhesions, which are sometimes few an« 1 sometimes wry numerous. Chronic 
pleurisy may be associated. 

* Jahrbuch fur Kindcrh., Bd. xviii, 420. 



420 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms. — The early symptoms are of a very indefinite character, 
such as a decline in the general health, or dyspeptic symptoms ; but often 
nothing whatever is noticed until the swelling of the abdomen begins. 
The enlargement comes on rather gradually in the course of a few weeks. 
Pain is slight, or wanting altogether. There may be some abdominal ten- 
derness, but this is rarely marked. The bowels are irregular ; sometimes 
there is diarrhoea and sometimes constipation. The abdomen is usually 
distended with fluid, the umbilicus protruding, and the superficial veins 
prominent. The enlargement is generally regular and symmetrical, and 
the wave of fluctuation is readily obtained. The general symptoms are 
very few. In some cases there is a slight evening rise of temperature of 
one or two degrees. There may be general weakness, loss of appetite, 
and moderate anaemia. 

The usual course of the disease is for the fluid to remain for a time 
and then undergo slow absorption, the case going on to complete recov- 
ery. Occasionally relapses are seen. The results are not always so favour- 
able, for in some instances there is no tendency to absorption of the fluid, 
the general health is gradually undermined, and the patients die from 
exhaustion or from some intercurrent disease. The diagnosis rests upon 
the presence of ascites, developing gradually without any signs or symp- 
toms of disease in the heart, liver, or other organs. The points which 
distinguish it from tubercular peritonitis are considered under that dis- 
ease. In the cases which recover, the fact that no other signs of tuber- 
culosis subsequently develop, is an important point in diagnosis. The prog- 
nosis is in most cases favourable, but must be guarded on account of the 
difficulty in making a positive diagnosis from the tubercular form. Ee- 
covery is usually complete and permanent. 

Treatment. — It is important that the patient should be kept at rest, 
preferably confined to bed. The best results are usually obtained by the 
adoption of a general tonic plan of treatment. If absorption of the 
fluid does not begin with such means, saline diuretics should be given and 
the amount of fluid allowed the patient, limited. When there is no tend- 
ency to absorption after a thorough trial of the above measures, and 
especially when the patient's general health begins to suffer, the fluid 
should be removed by aspiration. If it continues to accumulate after 
repeated aspirations, laparotomy may be performed, for in some cases 
this has the same beneficial effect as in tubercular peritonitis. 

TUBERCULAR PERITONITIS. 

The peritonaeum is quite frequently the seat of tubercular inflamma- 
tion in early life ; but not so often in infants as in older children. Of 
56 collected cases, 7 were under three years of age, 26 from three to eight 
years, and 23 from eight to sixteen years. In 119 autopsies upon tuber- 
cular patients, most of them under three years old, of which I have records, 



TUBERCULAR PERITONITIS. 421 

the peritonaeum was involved in 8*5 per cent. In 105 autopsies, for the 
most part upon older tubercular children, Ashby found the peritonaeum 
involved in 36 per cent. In 883 collected autopsies upon tubercular chil- 
dren of all ages, Biedert* found the peritonaeum involved in 18'3 per cent. 
These figures do not represent the number of cases of tubercular peri- 
tonitis, as in many of them only a few miliary tubercles were present. 

It is no doubt possible for peritonitis to occur as the primary lesion of 
tuberculosis, but in the great majority of cases it is secondary. It may, 
however, appear as the most important tubercular lesion in the body. 
The peritonaeum may be infected directly from the intestine, the mesenteric 
glands or the pleura, or from more distant parts, like the lungs, the bron- 
chial glands, the cervical, or other external glands. In a small number of 
cases some local exciting cause is present, such as a fall or blow upon the 
abdomen. It may follow exposure, or occur as a sequel to one of the 
exanthemata. 

Tubercular peritonitis may be acute or chronic. It presents several 
varieties quite distinct from one another, both in their pathological and 
clinical features. 

1. Miliary Tuberculosis of the Peritonaeum accompanying General Tu- 
berculosis. — The peritonaeum may be involved as one of the lesions in 
acute or subacute general miliary tuberculosis. This is the most common 
form seen in infants. The lesions consist in a deposit of miliary tuber- 
cles, which are generally rather sparsely scattered over the peritonaeum. 
The evidences of inflammation are very slight, or they may be absent alto- 
gether. These cases do not come under observation as cases of peritonitis, 
as there are no abdominal symptoms. 

2. Miliary Tuberculosis of the Peritonaeum with Ascites. — Although 
not the most common variety in children, these cases form an important 
group. The peritonaeum is thickly sown with miliary tubercles, both dis- 
crete and in conglomerate masses. They are found in the omentum and 
the mesentery, upon the surface of the intestines and the solid viscera. 
The peritonaeum shows in varying degrees the changes of acute or sub- 
acute inflammation. There is congestion, with the production of a mod- 
erate amount of fibrin and a large amount of serum. In the most acute 
cases the fluid is in the general peritoneal cavity. In those of longer du- 
ration it may be sacculated. The fluid is usually abundant, but not excess- 
ive. It is most commonly an olive-coloured serum, but it may be sero- 
purulent, and even bloody. There arc commonly other lesions of tubercu- 
losis in the body, but they are less marked than those of the peritonfflum. 

These ascitic cases generally run an acute or subacute course, the usual 
duration being from four to eight weeks. Clinically they presenl the 



*Jahrbuchfur Kinderh., xxi, 178 ; see also Osier, Johns Hopkins Bospital Etepi rts, 

vol. ii. 



422 DISEASES OF THE DIGESTIVE SYSTEM. 

symptoms of a moderate grade of peritoneal inflammation with ascites. 
The onset is rather gradual, with indefinite general symptoms. There is 
usually some fever — 100° to 101 # 5° F. There are general weakness, pros- 
tration, and loss of flesh, but not rapid emaciation. Vomiting is not 
prominent, and pain and tenderness are rarely very marked. There may 
be nothing distinctive until distention of the abdomen is seen. This at 
first is due to gas, but later to fluid, which may accumulate in sufficient 
quantity to fill the general peritoneal cavity. The bowels are constipated, 
or there may be diarrhoea. 

The usual course, when untreated, is for the disease to go on to a fatal 
termination from exhaustion. Less frequently the fluid is absorbed, and 
the case becomes one of the fibrous type, with a tendency to relapses; 
rarely it is followed by the ulcerative form. 

3. The Fibrous Form. — This, in its general characters, may be com- 
pared to the fibroid form of pulmonary tuberculosis. There is a tuber- 
cular inflammation, the products of which have undergone transfor- 
mation into fibrous tissue. This may in a certain sense be regarded as 
a method of cure. The essential feature of the lesion in these cases is the 
production of extensive organized adhesions between the intestinal coils, 
and between the intestines and the abdominal walls. The intestines may 
be compressed against the spine by bands. Ascites may be present, but it 
is frequently absent altogether. If there is fluid, it may be in the gen- 
eral peritoneal cavity, or it may be sacculated, and it may consist either 
of serum or of sero-pus. There is no tendency to caseation or breakiDg 
down. 

Clinically these cases are distinguished by their slow, irregular course. 
They are the most chronic of all the forms. The disease may be chronic 
from the outset, or it may follow the variety previously mentioned. The 
onset is generally insidious; fever is slight, or entirely absent. There 
is rarely vomiting. The bowels may be constipated or loose. For a 
long time the general health may remain good. The only characteristic 
symptom is the enlargement of the abdomen. In the early part of the 
disease this is chiefly from the tympanites, but later it may depend wholly 
or in part upon an accumulation of fluid. Ascites usually develops very 
slowly, but may be abundant. The adhesions of the intestines may give 
rise to irregularities in the outline of the abdomen. Ascites may be pres- 
ent for a time and then disappear spontaneously, and the general health 
may so improve that the patient is considered quite well. There may 
even be a permanent cure. In other cases, after symptoms have been 
absent for some time, relapses occur, and more fluid is poured out. In 
addition to these symptoms, others are present depending upon the me- 
chanical effects of pressure from the contracting adhesions. There may 
be more or less constriction of the intestine, pressure upon the vena cava, 
the renal or portal veins, the thoracic duct or its branches, or upon the 



TUBERCULAR PERITONITIS. 423 

stomach. These may give rise to dyspeptic symptoms, emaciation, oedema 
of the lower extremities, and albuminuria. 

In some cases the disease is entirely latent, and it is discovered at 
autopsy when there have been either no abdominal symptoms during life, 
or only colicky pains of an indefinite character. The course of this form 
is slow and irregular ; it generally lasts for from three to twelve months, 
although with intermissions and exacerbations it may extend over several 
years. The fatal result may be due to an acute exacerbation, to exhaus- 
tion, or to the development of tuberculosis elsewhere. 

4. The Ulcerative Form. — This is an inflammation associated with large 
tubercular deposits which go on to caseation and softening. It may be 
compared to ulcerative phthisis. In point of chronicity it is midway be- 
tween the two preceding varieties. It is one of the most frequent forms 
seen in children, and, while it may be localized, it is usually general. 

There is commonly a very abundant fibrinous exudate, matting the 
coils of intestine together and causing them to adhere to the solid viscera 
and to the abdominal walls. In this exudate there are seen tubercular 
deposits consisting of small, yellow nodules and larger caseous masses, 
often broken down at the centre. These caseous deposits are also 
found in the mesentery and in the omentum, which may be very greatly 
thickened. Pockets are formed by the adhesions which sometimes contain 
clear serum, but more frequently pus or a brownish fluid. The tuber- 
cular deposits are found upon the peritoneal surface of the intestine, and 
infiltrate the intestinal walls, often leading to perforation, and sometimes 
to fistulous communication between adherent intestinal coils. There may 
also be tubercular infiltration of the abdominal walls, accompanied by 
cellulitis, resulting in abscesses, which open externally, usually in the 
neighbourhood of the umbilicus. 

The ulcerative form may succeed either the miliary or fibrous form, 
or the inflammation may be of this type from the outset. Tubercular 
lesions are always found in the other organs, especially in the lungs, where 
they are usually advanced. 

Clinically the ulcerative cases are characterized by well-marked consti- 
tutional symptoms, which are due partly to the peritonitis and partly to the 
general tuberculosis. Fever is regularly present, the temperature usually 
ranging; from 99° to 103° F. Sometimes it assumes a distinctly hectic 
type. There are progressive emaciation, anaemia, prostration, and Bweatmg. 
Diarrhoea is frequent and the intestinal discharges may at times be bloody. 
The abdomen is large, but not so much distended as in some of the 
other forms; the superficial veins are often prominent. It 18 rare that 
ascites can be made out by palpation, although fluid can usually he found 
by puncture. Areas of dulness and tympanitic resonance arc irregularly 
distributed over the abdomen. Nodular masses from one to two inches in 
diameter may be felt on palpation. The epigastric and umbilical regions 



424 DISEASES OF THE DIGESTIVE SYSTEM. 

may be occupied by a smooth, hard, and board-like tumour, which is the 
thickened omentum. There may be the signs of phlegmonous inflamma- 
tion of the abdominal wall in the neighbourhood of the umbilicus, and 
even an abscess, which, after opening, may leave a fistulous communication 
with the peritonaeum. There are signs of disease in the lungs, and the 
pulmonary symptoms may mask those of the abdomen. The course of 
the disease is steady and progressive, the usual duration being two or 
three months. Death results from the pulmonary disease, from tubercular 
meningitis, from exhaustion, and occasionally it is due to accidents as- 
sociated with perforation. 

5. Peritonitis associated with Tuberculosis of the Mesenteric Lymph 
Nodes. — These nodes may be tubercular in any of the preceding varieties. 
In certain cases this is the principal lesion, and it is accompanied by lo- 
calized peritonitis, which results in the formation of a large, irregular, 
nodular mass lying close against the spine. It is usually associated with 
tubercular ulcers of the intestine. There may be no symptoms except 
those depending upon the pressure of the glandular masses upon the great 
vessels. This may lead to oedema or to thrombosis of the vena cava, and 
may give rise to an abdominal tumour. There may be diarrhoea due to 
the intestinal lesions. 

Diagnosis of Tubercular Peritonitis. — In children, chronic ascites with 
fever usually means tubercular peritonitis. If the abdominal effusion is 
sacculated instead of diffuse, the probabilities of peritonitis are much in- 
creased. If there are added the physical signs and symptoms of disease of 
the lungs, the diagnosis is almost certain. Cirrhosis of the liver is much 
more chronic in its course, and is very rare previous to the ninth year, 
being almost unknown in infancy and early childhood. In it there is 
often a history of syphilis, and jaundice may be present. If ascites is ab- 
sent, tuberculosis of the peritonaeum may be suspected if there are irreg- 
ular nodules or tumours in various parts of the abdomen, with tenderness, 
emaciation, moderate pain, and slight fever. Chronic abscess in the neigh- 
bourhood of the umbilicus is always suspicious. The ulcerative form is 
almost invariably accompanied by evidences of advanced disease in the 
lungs and other organs, and is easily recognised. The fibroid form may 
be suspected if, with tuberculosis of other organs, there are irregular 
colicky pains and abdominal tenderness. From the abdominal symptoms 
alone it can not be recognised unless there is ascites. In all doubtful 
cases an exploratory incision should be made. 

Between tubercular and non-tubercular chronic peritonitis a diagnosis 
is at times impossible. If there is a good family history ; if there are no 
signs of tuberculosis in the lungs or elsewhere ; if abdominal tenderness is 
slight or absent ; if there are no nodular tumours ; if fever and marked 
emaciation are wanting ; and if the amount of fluid is excessive, the prob- 
abilities are in favour of a simple inflammation. There are, however, 



TUBERCULAR PERITONITIS. 425 

some cases in which the diagnosis can be made only by an exploratory in- 
cision, and sometimes not even then without an examination of the fibrous 
nodules by the microscope or by inoculation. In doubtful cases the 
chances are always in favour of tubercular inflammation on account of its 
greater frequency. 

Prognosis.— This depends most of all upon the form of the disease. 
Cases of the ulcerative type are absolutely hopeless. In the ascitic and 
fibrous forms, the prognosis is quite good, especially since the general 
adoption of laparotomy as a means of treatment. Life is prolonged in 
nearly all cases by the operation, and a considerable number are perma- 
nently cured. Exactly in what proportion a permanent cure results, it is 
at present impossible to say, for most of the reported cases were not under 
observation long enough to make it certain that relaj)ses did not occur. 

Treatment. — The general treatment of tubercular peritonitis is the 
same as that of tuberculosis in other parts of the body. In the acute 
cases the local symptoms are to be relieved by the same means as in other 
forms of acute peritonitis. The only local treatment which can be con- 
sidered in any way curative is surgical. Nothing is to be said in favour of 
aspiration except for purposes of diagnosis. The results of laparotomy are 
so satisfactory that the question of operation should be considered in every 
case. The most favourable cases for operation are those of the ascitic 
variety. Aldibert,* in his monograph, gives the indications and contra- 
indications for operation as follows : Laparotomy is indicated in all forms 
accompanied by ascites, although in acute cases it may be only palliative ; 
in suppurative forms which are diffuse, or with a unilocular cyst ; in all 
cases of intestinal obstruction in the course of tubercular peritonitis ; and 
in all cases of doubtful diagnosis. Operation is contra-indicated in the 
fibrous form not attended by pain, this usually tending to spontaneous re- 
covery ; in the dry ulcerative form, except at the outset ; in the suppura- 
tive form with multilocular cysts. The existence of other foci of tuber- 
culosis does not contra-indicate operation except when these are chiefly 
intestinal, or when there is general tuberculosis with extensive and rapidly 
progressing lesions. 

Aldibert has collected statistics of fifty-two operations for tuber- 
cular peritonitis in children, with seven deaths and forty-five recoveries' 
Nine patients were reported well one year after operation. It is possible 
that among these cases some of simple inflammation have been included ; 
of eighteen cases, however, in which the diagnosis of tuberculosis \\;is 
established by the microscope or inoculation experiments, all recovered, and 
six were well one year after operation. Why it is that the operation <>f 
opening the abdomen and draining or washing out the peritoneal cavity 
should have such an influence in arresting the disease, lias not yet 



*De la Laparotomie dans la P6ritonite Tuberculeuse ohez L'Enfant, Paris, L893. 



426 DISEASES OF THE DIGESTIVE SYSTEM. 

been satisfactorily explained. For the surgical aspect of the treatment 
the reader should consult works upon surgery. 

ASCITES. 

Ascites consists in an accumulation of fluid, usually clear serum, in the 
general peritoneal cavity. It is a symptom of the various forms of peri- 
tonitis, especially the chronic varieties described in the preceding pages. 
It may be due also to portal obstruction from cirrhosis of the liver, or 
pressure upon the portal vein by peritoneal adhesions or large lymphatic 
glands. It is occasionally seen in all forms of abdominal tumours. As- 
cites may occur in general dropsy from cardiac disease, chronic pleurisy, 
or interstitial pneumonia, and from any condition causing pressure upon 
the vena cava. It is also seen in the general dropsy of renal disease. A 
moderate amount of ascites is often met with in extreme anaemia or 
leukaemia. 

Small accumulations of fluid in the peritoneal cavity are difficult of 
detection. Large amounts are generally easily made out. There is a uni- 
form smooth distention of the abdomen and dilatation of the superficial 
veins, especially about the umbilicus. On palpation, the wave of fluctu- 
ation can be obtained by placing one hand against the abdomen upon one 
side and giving the opposite side a sharp tap. A similar wave may be felt 
when there is tympanitic distention. The two are, however, readily dis- 
tinguished by having an assistant make pressure with the edge of the hand 
along the linea alba while the test is being made ; this obstructs the wave 
transmitted through the abdominal wall, but does not affect that through 
the fluid. On percussion in the sitting posture, there are dulness below 
and resonance above. When the patient is recumbent, there are resonance 
in the median line and dulness or flatness in the lateral portion of the 
abdomen. 

The prognosis and treatment of ascites will depend upon its cause. 

Chylous Ascites. — This term is applied to certain cases in which the 
abdominal fluid contains fat. The colour may be milky-white or light 
brown, and the fluid, after standing, may have at its surface a thick, 
creamy layer. The amount of fat present has been as high as five per cent. 
This condition is rare in childhood. In 1884, Letulle* could find but 
seven cases on record. The exact pathology is as yet not well understood. 
In the cases which have thus far come to autopsy there has usually 
been found chronic peritonitis, sometimes simple, sometimes tubercular. 
The lymph vessels in some of the cases have been empty, and often no 
obstruction of the lymph circulation could be discovered. The fat is 
believed by some to be derived from fatty degeneration of the products of 
chronic inflammation, but this seems hardly sufficient to explain the large 

* Revue de Medicine, 1884, No. 9. 



SUBPHRENIC ABSCESS. 427 

amount of fat sometimes found. In some of the cases it has been due 
to a wound of the thoracic duct. The amount of fluid is frequently very 
large. The prognosis is usually bad, although Pounds has reported (Brit- 
ish Medical Journal, 1892) a case in a girl of ten years, where recovery 
followed laparotomy. Tubercular peritonitis was present. 

SUBPHRENIC ABSCESS. 

In the group of cases of localized peritonitis or peritoneal abscess must 
be included subphrenic abscess. This is a rare condition in childhood, 
and consists in an accumulation of pus just beneath the diaphragm and 
above the liver. Its cause may be either in the thorax or in the abdomen. 
It may complicate acute pneumonia, usually of the right lower lobe, by a 
direct extension of infection through the lymph channels. Sometimes 
it has been associated with phthisical cavities. In the abdomen it may be 
associated with disease of the liver. The accumulation of pus is some- 
times very great, so that the diaphragm is crowded high into the thorax. 

The symptoms and physical signs closely resemble those of empyema, 
and most of the cases have been operated upon with the belief that the 
surgeon was dealing with empyema. Meltzer* has reported a case in a 
child of two years which followed pneumonia of the right base. At the 
operation only a few drops of pus were found in the pleural cavity ; but 
there was discovered a pinhole opening in the diaphragm, from which the 
pus had escaped from a large subphrenic abscess. This was evacuated, 
and the patient recovered perfectly. Subphrenic abscesses may contain 
air ; they are then likely to be mistaken for pneumothorax. These ab- 
scesses require incision and drainage like other forms of peritoneal abscess. 

* New York Medical Journal, June 24, 18U3. In this article will be found refer- 
ences to the recent literature. 



SECTION IT. 
DISEASES OF THE RESPIRATORY SYSTEM. 

CHAPTER I. 

NASAL CAVITIES. 

ACUTE NASAL CATARRH— CORYZA. 

Although the symptoms of this disease are nasal, the principal seat 
of the pathological process is the rhino-pharynx. 

Etiology. — Certain children are predisposed to attacks of acute nasal 
catarrh. This predisposition, as it sometimes extends to entire families, 
may be inherited ; but more frequently it is acquired, and usually by the 
following mode of life : It is seen in children who get very little fresh air, 
because they are kept indoors unless the weather is perfect ; who live in 
houses always overheated ; whose sleeping rooms are kept carefully closed 
at night for fear they may take cold ; who are for the same reason so over- 
loaded with clothing that they can not engage in any active play without 
being thrown into a profuse perspiration. This condition after a time 
results in a great sensitiveness of all the mucous membranes, but especially 
those of the nose and pharynx. A small adenoid growth is very often 
present. Infants under three months old, and those who are rachitic, are 
frequent sufferers from acute nasal catarrh. It may be seen as a compli- 
cation of dentition. Attacks are often brought on by insufficient covering 
for the head, by wetting the feet, by cold and exposure, especially to the 
raw winds of spring, accompanied by the dampness which occurs with 
melting snow. In susceptible children the exciting cause is often a very 
trivial one. A draught of cold air for a few miuutes may be sufficient to 
excite sneezing and a nasal discharge. Atmospheric conditions are prob- 
ably not the only cause of acute nasal catarrh. Micro-organisms certainly 
play an important part, particularly in the purulent variety. Although 
pyogenic germs are always present in the nose, they do not excite an 
attack of acute catarrh without the vascular changes which are produced 
by other causes. Acute catarrh may be sporadic or epidemic ; it is prob- 
ably contagious, being communicated by children using the same hand- 
kerchief or occupying the same bed. 

Acute nasal catarrh may be a symptom of measles, nasal diphtheria, or 
influenza, and it may accompany erysipelas of the face. 

428 



ACUTE NASAL CATARRH. 429 

Symptoms. — The changes in the mucous membrane of the nose are not 
great, and are usually secondary to those of the rhino-pharynx, being in a 
large measure due to the discharge. There are redness and slight swell- 
ing. The nasal passages may be for the time quite occluded by the dis- 
charge, which is usually profuse, at first sero-mucous, and finally, if the 
attack is severe, muco-purulent. The symptoms may be very transient, 
sometimes passing away in a few hours, in which cases there is only a vaso- 
motor disturbance ; or they may continue and develop into a true inflam- 
mation. The discharge excoriates the nostrils and the upper lip. At the 
onset there is usually sneezing, and in infants often a slight fever. In 
older children there is no rise of temperature except in the most severe 
cases. The obstruction to nasal respiration causes mouth-breathing, and the 
dryness and discomfort which result from it produce disturbed sleep, snuf- 
fling and difficulty in nursing, this being in severe cases almost impossible. 
The inflammation may extend to the lachrymal duct, involving the eyes in 
a mild conjunctivitis. There may be closure of the Eustachian tubes, 
causing deafness and otalgia. There may also be secondary otitis. The 
process often extends to the larynx and bronchi, with hoarseness and cough. 

In infants, severe cases may be followed by inflammation of the lymph 
glands of the neck or of the retro-pharyngeal region ; in either it may ter- 
minate in abscess. Less frequently these catarrhal colds are accomjmnied 
by disturbances of the digestive tract, and there is vomiting, or diarrhoea 
with large mucous stools. 

Attacks of acute nasal catarrh are stated by some writers to cause 
death in young infants by interfering with respiration. I have never 
seen dangerous symptoms, and believe them to be exceedingly rare, if, in- 
deed, they ever occur as a result of a simple coryza. In the mild form 
the attack lasts from two to three days; in the severe form from one 
to two weeks. Repeated attacks are frequently followed by the develop- 
ment of the chronic form of the disease. 

Diagnosis. — It is important to distinguish between a simple acute ca- 
tarrh and one due to measles, influenza, nasal diphtheria, or hereditary 
syphilis. Measles and influenza cause more fever and general constitu- 
tional disturbance than does simple catarrh. Nasal diphtheria is charac- 
terized by the appearance of membrane in the anterior nares and by 
patches upon the tonsils. These may be wanting, however, and there may 
be only a very profuse discharge tinged with blood. When persisting for 
two or three weeks this is always to be regarded with suspicion, even though 
the constitutional symptoms may be very slight. The only positive means 
of excluding diphtheria is by cultures. A persistent acute nasal catarrh in 
a young infant should always suggest syphilis, and the patient should be 
carefully watched for the development of other symptoms. 

Treatment— A child suffering from acute coryza should always he kept 
indoors in a room with an even temperature of about 70° F., the bowels 



430 DISEASES OF THE RESPIRATORY SYSTEM. 

freely opened, and the amount of food somewhat reduced. The only drug 
which seems to have much influence upon the secretion is belladonna. 
This may be given in the form of atropine, gr. -g-J-g- every hour to a child 
of six months. For older children a good combination is that known as the 
" rhinitis " tablet (camphor gr. £, quinine gr. J, fluid extract of belladonna 
nt i) ; one half a tablet may be given every hour to a child of five years. 

Locally, either plain sweet oil or albolene may be applied by means of 
a medicine dropper, a brush, or a spray (page 55), an alkaline spray (page 
56) having been first used to clear away the secretion. If the nasal ob- 
struction causes great interference with nursing, a two-per-cent solution 
of cocaine may be applied with a brush, or with a probe and cotton, or 
dropped into the nostril just before each nursing. This is not to be ad- 
vised unless the symptoms are severe, as infants are quite susceptible 
to cocaine. In all cases the upper lip and nostrils should be protected by 
vaseline or some simple ointment. Under no circumstances should irri- 
tating or astringent injections be given. In older children inhalations of 
spirits of camphor or fumes of carbolic acid may be used with advantage. 

Prophylaxis consists in solving the perplexing question, so often put to 
the physician, of how to prevent children from "taking cold." This is a 
matter of the utmost importance, and follows what has been previously 
said under the head of Etiology. No amount of cod-liver oil and iron 
will remove this tendency to catarrh so long as bad hygienic conditions 
continue. Sleeping rooms should be large and well ventilated, and a 
window should be kept open at night, except in very severe weather or 
during acute attacks. The temperature of the house during the day should 
be from 68° to 70° F., but never above this. Children should be accus- 
tomed to go out of doors unless the weather is especially bad. So firmly 
rooted in the minds of the laity is the idea that acute catarrhs come from 
cold, that the habit of coddling delicate children is always likely to be 
carried to an extreme. 

With every delicate and " catarrhal " child one should begin in the 
summer by having him live in the open air as much as possible, sleeping 
in a room with free ventilation, with moderate covering, and continuing 
the same practice into the fall and early winter. If begun gradually in 
this way there is little difficulty in continuing throughout the winter. 

The next point to be insisted on is cold sponging immediately upon 
rising in the morning, especially about the chest, throat, and spine (page 
55). The use of chest protectors, cotton pads, and extremely thick cloth- 
ing should be prohibited. Flannel underclothing should be worn upon 
the chest throughout the year, and upon the legs also in winter ; the very 
lightest in summer, and only a medium weight in winter. 

Frequently repeated attacks point to the presence of adenoid vegeta- 
tions in the pharynx, and no measures are of much avail until these are 
removed. 



CHRONIC NASAL CATARRH. 431 



CHRONIC NASAL CATARRH. 

This term is rather loosely used to designate a chronic nasal discharge. 
Such a discharge is frequent both in infancy and childhood. It is a con- 
dition much neglected by the general practitioner. Patients are too often 
subjected to routine constitutional treatment by cod-liver oil and prep- 
arations of iodine, with the idea that such cases are " scrofulous," while 
local treatment is either neglected altogether, or consists only of the use of 
the nasal douche or syringing with a saline solution. Sometimes, when 
suggested by parents, local treatment is opposed by the physician in the 
case of young children, and a great amount of harm follows. Permanent 
damage to the organs of hearing, smell, speech, and respiration may result 
from neglecting or ignoring chronic nasal catarrh in childhood. 

Chronic nasal catarrh is not to be regarded as a disease, but only as 
a symptom which may be due to any one of a variety of pathological con- 
ditions, each of which requires very different treatment — viz., adenoid 
growths of the pharynx, foreign bodies in the nose, polypi, deviation 
of the septum or any other congenital deformity of the nasal passages, 
the various forms of chronic rhinitis, and syphilis, which causes a form of 
rhinitis peculiar to itself. 

Adenoid Growths of the Pharynx. — These are more fully discussed 
elsewhere (page 263). They are by far the most frequent cause of chronic 
nasal discharge in infants and young children, and should be the first 
cause suspected. Every general practitioner may easily familiarize him- 
self with the method of digital exploration of the rhino-pharynx, by 
which means these growths can in most cases be easily recognised. The 
nasal discharge accompanying adenoid growths is due to a chronic rhino- 
pharyngitis. Treatment is without avail unless the growths are removed. 
After this is done the nasal discharge usually disappears quite promptly. 

Foreign Bodies in the Nose. — This condition should be suspected 
whenever there is an abundant muco-purulent discharge limited to one 
nostril. Foreign bodies in the nose are quite frequent in young children. 
Peas, beans, beads, or shoe buttons are most frequently lodged there. The 
efforts at removal on the part of the child, or even of the mother, gener- 
ally result in pushing the body farther into the nose. It first sets up a 
mechanical irritation, accompanied by pain, swelling, sneezing, and some- 
times hemorrhage. This is followed by a catarrhal inflammation, which 
in the course of a few days becomes purulent, and may last indefinitely. 
The discharge is generally quite abundant. The symptoms point to an 
obstruction of one nostril, and an examination with the probe readily de- 
tects the presence of the foreign body. 

In recent cases the removal of the foreign body may sometimes he ac- 
complished by compressing the empty nostril and having the child blow 
his nose strongly. Often the sneeziDg which the body excites is suflii 



432 DISEASES OF THE RESPIRATORY SYSTEM. 

to remove it. Before any attempt is made to seize the body with forceps 
cocaine should be used, not only for the purpose of preventing pain, but 
in order to shrink the mucous membrane so as to allow better manipula- 
tion. In many cases chloroform is necessary. In most circumstances 
ordinary foreign bodies can with proper forceps be extracted without diffi- 
culty. No subsequent treatment is required, except to keep the nose 
clean for a few days, as the inflammation quickly subsides after the re- 
moval of the cause. 

Nasal Polypi. — These are among the infrequent causes of chronic 
nasal discharge in childhood. They are especially rare before the seventh 
year, but both mucous and fibrous polypi are seen. The symptoms are 
those of a chronic nasal catarrh with partial or complete obstruction of 
one or both sides. Polypi increase in size with the occurrence of every 
acute coryza, and are always especially troublesome in damp weather. 
They may be accompanied by reflex symptoms, such as cough, sneezing, 
and even by attacks of asthma. There may be headache, and sometimes dis- 
turbances of smell, taste, and hearing. The symptoms are of much longer 
duration than in the case of obstruction from a foreign body, the discharge 
is not so abundant, and is not purulent. The diagnosis is made only by 
examining the nose with the mirror and nasal speculum. 

Polypi may be removed with the forceps, but this is best accomplished 
by the use of the wire snare. When they have been present for a long 
time the accompanying chronic rhinitis may require subsequent treat- 
ment. 

Deviation of the nasal septum, and other congenital deformities which 
cause narrowing of the nasal respiratory tract, are conditions which belong 
to the specialist. 

CHRONIC RHINITIS. 

Three forms of chronic rhinitis are recognised — simple, hypertrophic, 
and atrophic. 

Simple Chronic Rhinitis. — Simple chronic rhinitis existing alone is of 
very doubtful occurrence in young children. In the cases so classed the 
symptoms are due to rhino-pharyngitis, which almost invariably depends 
upon an adenoid growth. 

The growth may be a small one, so that the symptoms of obstruction 
are slight or absent. A frequent complication is chronic enlargement of 
the cervical lymph glands. 

The only constant symptom is an excessive nasal discharge, which is 
usually mucous, but which may be muco-purulent. It is easily removed 
by blowing the nose, if the child is old enough to be taught to do this. 
Children too young to clear the nose in this way, surfer from almost con- 
stant discomfort. The amount of discharge depends upon the soverity of 
the case. It frequently causes irritation of the upper lip, which may be 



CHRONIC RHINITIS. 433 

the seat of eczema or impetigo, especially in infants. The lip may be 
swollen and prominent. The condition of the external parts is aggravated 
by the constant disposition to pick the nose, which may be overcome by 
the use of a short anterior splint to each elbow. This condition is often 
the cause of epistaxis. The duration is indefinite ; it may last for 
months or even for years, the symptoms in summer being insignificant, 
but returning every cold season. It may terminate in recovery, or in chil- 
dren with flabby tissues and delicate constitution, it may be followed in 
later childhood by hypertrophic rhinitis. 

Treatment. — Prophylaxis is very important. The main purpose should 
be to prevent attacks of acute nasal catarrh by the measures mentioned in 
the discussion of that disease. The general treatment should not be 
routine, but directed according to the indications of each case. There 
should be careful attention to diet and to the condition of the bowels. 
Iron and arsenic are needed when there is anaemia. A general tonic treat- 
ment is required in most cases. Cod-liver oil and the syrup of the iodide 
of iron are both useful, but are not specifics, and must be intelligently 
combined with other measures. 

Local treatment consists first in cleanliness, and, secondly, in the use 
of astringents in the form of powder or solution. For cleansing, a solu- 
tion which is both alkaline and antiseptic is desirable. This may be used 
in the form of a spray, after which the nose is cleared by blowing ; or in 
infants, if the discharge is abundant, the only efficient method of getting 
rid of it is by nasal syringing. This is attended by some risk of forcing 
materials into the middle ear ; but if carefully done, the danger seems 
to me to be less than that of allowing the discharge to remain. Syring- 
ing should always be done with the mouth open and the head inclined 
forward. All solutions are to be made with sterilized water and used 
warm. But little force should be employed, and it may be well to have 
a syringe the nozzle of which does not completely fill the nostril. Either 
DobelPs or Seller's solution (page 56) may be employed, diluted with an 
equal amount of water. As a spray the following may be used : 

B Listerine * 1 ss « 

Sodii bicarb., 

Sodii biborat 8a 3 bs. 

Aquae 3 1V - 

If this is to be used with a syringe, twice as much water should be added. 
Ordinarily, the nose must be cleansed thoroughly twice a day, more fre- 
quently in very severe cases. Once a day, after the nose has been cleansed, 
an astringent solution or powder should be applied. One of the best boIu- 

* Listerine is a combination containing the essential oils of thyme, eucalyptus, bap- 
tisia, gaultheria, and nicntha arvensis. 
34 



434 DISEASES OF THE RESPIRATORY SYSTEM. 

tions is sulpho-carbolate of zinc (gr. v to water § j). This may be used 
as a spray, or, better, dropped into the nostril with a medicine dropper, 
the head being held far back. A good powder is a combination of salicylic 
acid gr. iij, tannic acid, gr. xxx, and stearate of zinc \ j, which may be 
used with an insufflator once daily. 

Hypertrophic Rhinitis. — This is a chronic inflammation of the nasal 
mucous membrane, accompanied by a marked hypertrophy of all its nor- 
mal structures, particularly its blood-vessels. The parts chiefly affected 
are those covering the inferior turbinated bones. The mucous membrane 
and submucous tissue are so thickened and relaxed that they may greatly 
encroach upon the nasal respiratory space, and when these venous sinuses 
are filled with blood, may entirely occlude the passage. There is usually 
associated with this condition some degree of hypertrophy of the adenoid 
tissue at the pharyngeal vault. 

In young children hypertrophic rhinitis is a very infrequent disease, if, 
indeed, it ever occurs. It is fairly common in moderate degree in older 
children, although its severe forms are rare. It usually follows repeated 
attacks of acute nasal catarrh in children who have the diathesis " lympha- 
tism." A frequent local cause is a deflected nasal septum. 

The symptoms are those of nasal catarrh with bilateral nasal stenosis. 
The discharge is usually abundant, thick, and tenacious, being increased by 
dust and dampness. All the symptoms of nasal obstruction are present in 
varying intensity — the " wooden " voice, mouth-breathing, disturbed sleep, 
etc. There may be reflex cough, catarrh of the larynx or bronchi, accom- 
panied by muscular or vaso-motor spasm, giving rise to spasmodic croup or 
asthma. Rhinoscopic examination shows the large pendulous masses of 
mucous membrane, usually red and irregular, more or less completely 
blocking the nasal passage. It is only by this examination that the dis- 
ease is differentiated from adenoids of the pharynx, with which, however, 
it is frequently associated. In infants and young children the adenoid 
growth is much the more frequent, and throughout childhood generally 
the more important factor in producing these symptoms. 

The treatment of these cases falls largely to the specialist, although 
very much can be done by the general practitioner if he will learn to use 
intelligently a few remedial agents. Constitutional treatment is indicated 
as in simple rhinitis, but if employed alone it accomplishes little or noth- 
ing. The purpose of local treatment is the reduction of the hypertrophied 
tissue by cauterization under cocaine anaesthesia, by glacial-acetic or chro- 
mic acid, or by the gah r ano-cautery. Each has its advantages and its ad- 
vocates. If the hypertrophied tissue forms pendulous tumours, it may be 
removed by the wire snare. Both nostrils should not be operated upon at 
the same time. In most cases cauterization must be repeated several times 
at intervals of a few weeks. In the meantime one of the cleansing solu- 
tions mentioned on page 56 may be employed. 



CHRONIC RHINITIS. 435 

The following formula of Lefferts is an excellent one for a spray to 
be used in this condition : 

5 Iodi gr. iv 

Potass, iodidi gr. x 

Zinci iodidi, 

Zinei sulpho-carbolat aa gr. xx 

Listerine § j 

Aquae § iv 

To be used as a spray once daily. 

Atrophic Rhinitis {Fetid Catarrh). — This is unknown in young chil- 
dren, and only occasionally seen in those over twelve years old. It is char- 
acterized by the formation of crusts in the nose, which decompose and 
produce the horribly fetid odour. By some writers the term ozcena is ap- 
plied to this disease, but usually this term is limited to rhinitis associ- 
ated with disease of the bones. Atrophic rhinitis has been regarded by 
some as the late stage of the hypertrophic form. This view, however, is 
strongly combatted by Bos worth, who considers it the result of a puru- 
lent form of acute rhinitis. The changes consist in an atrophy of the 
mucous membrane and the destruction of many of the secreting glands. 
The nasal fossae are large and roomy. The voice is not affected, but the 
sense of smell may be much impaired. There are no symptoms of ob- 
struction. The discharge is scanty, and tends to accumulate between the 
bones, forming large crusts, which are expelled with difficulty by blowing 
the nose. 

In the severe cases the treatment is only palliative, yet this is of the 
utmost importance for the comfort of the patient and those about him. 
The object of treatment is to prevent as much as possible the forma- 
tion of crusts by the frequent use of an oil spray, such as albolene, in 
order to coat the dry mucous membrane. For the removal of crusts they 
must first be macerated by a prolonged nasal douche as hot as can be 
borne. This should be thoroughly used morning and evening as a part 
of the patient's toilet. In employing the douche, a bag containing from 
one to two pints should be suspended a few inches above the patient's 
head. One of the alkaline and antiseptic fluids mentioned on page 56 
may be added to the douche. The head should be slightly inclined for- 
ward and the mouth kept open during the douche. The mechanical 
removal of the crusts maybe necessary if they are large, hard, and im- 
pacted. Benefit may be derived in some cases from the daily use of a 
stimulating spray containing ten grains of menthol fco one ounce of albo- 
lene. One of the very best deodorizers for general use is listerine, which, 
diluted with two or three parts of water, may be employed as a Bpraj 
eral times a day, in addition to the other measures mentioned. 

Syphilitic Rhinitis. — Rhinitis is seen both in early and late hereditary 
syphilis. Coryza, or snuffles, is one of its earliest and most constant 



436 DISEASES OF THE RESPIRATORY SYSTEM. 

symptoms. It usually begins between the third and sixth weeks of 
life, rarely after the third month. The pathological condition is a sub- 
acute catarrhal rhinitis, sometimes with the formation of superficial 
ulcers or mucous patches. The disease is attended by a profuse discharge 
of sero-mucus or muco-pus, occasionally tinged with blood. It may con- 
tinue from a few weeks to two or three months. It usually requires only 
constitutional treatment, and protection of the nostrils and lips by the use 
of the ointment of the yellow oxide of mercury diluted with four parts of 
vaseline. This may be introduced with the finger or brush for some dis- 
tance into the nostrils. When the discharge is very abundant, any one 
of the cleansing solutions previously mentioned may be used as a spray. 

The rhinitis of late hereditary syphilis is a very different patholog- 
ical condition. There are here gummatous deposits which break down, 
and form ulcers of the mucous membrane and deeper tissues. There is 
also periostitis, with extension of the disease to the cartilages and bones 
of the nasal fossae, particularly of the septum. There may be perforation 
of the triangular cartilage, necrosis of the vomer or nasal bones, perfora- 
tion of the hard or soft palate, and at times extensive ulceration of the alas 
nasi and the face. This may be followed by cicatrization, causing stenosis 
of the nostril. These lesions in the nose are generally accompanied by 
deep ulceration of the pharynx and soft palate. They usually occur in 
children who have presented the early symptoms of hereditary syphilis, 
but are occasionally seen when no such history can be obtained. Such was 
the case in a patient recently under observation in the Babies' Hospital, 
who had perforation of the nasal septum and of the floor of the nasal 
fossae, causing a free communication with the mouth. These are cases of 
true ozaena. The odour from the discharge is at times almost intolerable. 
When neglected, these cases go on from bad to worse, and may continue 
for years, producing unsightly deformities. 

The treatment is, to bring the patient fully under the influence of 
mercury, first by means of the mercurial ointment or by small doses of 
calomel — i. e., one tenth grain four or five times a day. Later the bin- 
iodide or the bichloride should be substituted, and iodide of potassium 
given in doses of ten to twenty grains three times a day. Tonics are 
needed in most cases, as the general health is frequently undermined and 
the patients are usually anaemic. 

Locally there may be used a spray of one of the cleansing solutions 
already mentioned, or black wash, or a solution of bichloride, 1 to 10,000. 
For purposes of deodorization, listerine is one of the best remedies. 
Although improvement may take place quite promptly, the results of 
treatment are often unsatisfactory, as the disease has usually progressed 
so far before treatment is begun that some deformity of the nose results, 
usually a sinking in of the bridge and flattening of the alas, giving rise to 
the so-called " saddle-back " deformity. 



PSEUDO-MEMBRANOUS RHINITIS. 437 



PSEUDO-MEMBRANOUS RHINITIS. 

The results of bacteriological examinations have shown that these 
cases, whose etiology was formerly the subject of considerable controversy, 
are nearly always due to the Loeffler bacillus, and hence are to be regarded 
as true nasal diphtheria. It has been difficult, from clinical features 
alone, to establish this relationship, as the disease differs in several impor- 
tant particulars from diphtheria of the pharynx and rhino-pharynx — viz., 
its prolonged course, the absence of glandular enlargements, and the pres- 
ence of very mild constitutional symptoms, which are sometimes alto- 
gether wanting. These peculiarities are due to the very slight absorption 
which takes place from the nose, which is in striking contrast with that 
from the rhino-pharynx. The importance of recognising such cases as 
true diphtheria can not be overestimated, as they have often been the 
means of spreading infection in schools and institutions before their true 
nature was determined. The possibility of pseudo-membranous inflamma- 
tion of the nose arising from other micro-organisms than the Loeffler 
bacillus is not to be denied, but such cases are extremely rare. 

The most striking clinical feature of primary nasal diphtheria is a 
nasal discharge of serum or sero-mucus, frequently streaked with blood. 
It is sometimes very abundant, at other times slight. There are also the 
symptoms of moderate nasal obstruction. The false membrane can in 
most cases be seen in the anterior nares as a gray or whitish exudation. 
It may cover the whole inner surface of the nose. It often remains for 
two or three weeks, when it may loosen and come away en masse, some- 
times forming an entire cast of the nose. After forcible removal it may 
reform. The disease in very many cases remains limited to the nose, but 
it may at any time extend to the rhino-pharynx or to the larynx. When 
such an extension takes place it is accompanied by an increase in the con- 
stitutional symptoms, glandular swellings, etc. A positive diagnosis can 
be made only by means of cultures. 

In addition to the general treatment for diphtheria, the nose in these 
cases should be syringed frequently with a warm saturated solution of 
boric acid, or bichloride 1 to 10,000, with 5 per cent of glycerin. Such 
cases must be isolated, like ordinary cases of diphtheria. 

EPISTAXIS. 

The haemorrhage may come from any part of the nasal \'<><^\, but it 
is generally from the anterior nares, and most frequently from the ves- 
sels of the septum. Epistaxis is a rare symptom in the haemorrh; 
of the newly-born, and when present indicates syphilis. It is infrequent 
throughout infancy, but in childhood it is quite common, occurring in 
boys more frequently than in girls. In the latter it is especially common 



438 DISEASES OF THE RESPIRATORY SYSTEM. 

about the time of puberty. Children who are kept much indoors in over- 
heated apartments, and who have susceptible mucous membranes and 
flabby tissues, are particularly prone to it. The exciting cause may be a 
local one, like a fall or blow ; it may be due to picking the nose, or to 
any kind of mechanical irritation ; it may be associated with nasal ca- 
tarrh ; and it is often caused by an erosion upon the septum. An attack of 
bleeding may be brought on by mental or physical excitement. It occurs 
as an occasional, often an early symptom, in typhoid or malarial fever, in 
measles, or during severe paroxysms of pertussis. It is seen in the hem- 
orrhagic form of all the eruptive fevers, in certain cases of diphtheria, 
most commonly late in the disease, in haemophilia and scorbutus, in grave 
anaemia, leukaemia, and in diseases of the heart and blood-vessels. 

Symptoms. — Epistaxis is frequently preceded by a sense of fulness or 
pain in the head, which is relieved by the bleeding. The blood is usu- 
ally from one nostril, and comes slowly by drops. The amount lost is 
generally small, but it may be large enough, when repeated, to produce a 
serious grade of anaemia even in strong children, and it has been the 
cause of death. Epistaxis may be overlooked if the blood finds its way 
into the pharynx and is swallowed. In most of the cases the haemor- 
rhage ceases spontaneously in from ten to twenty minutes, recurring at 
longer or shorter intervals, according to the nature of the cause. Haem- 
orrhage from adenoid growths of the pharynx may closely resemble that 
from the nose, but otherwise there can rarely be any difficulty in recog- 
nising epistaxis. In doubtful cases an inspection of the pharynx reveals 
the presence of blood-clots. 

Prognosis. — This depends upon the cause. In the great majority of 
the so-called idiopathic cases it is not serious. Occurring early in the 
course of the infectious diseases it does not ordinarily affect the prognosis 
unless it is very severe. When it occurs late, however, it is always a bad 
sign, and particularly so in diphtheria. It may be serious in any of the 
haemorrhagic diseases or in diseases of the blood, where it is not infre- 
quently a cause of death. 

Treatment. — To remove the predisposition, a child should receive 
general tonic treatment, especially plenty of outdoor exercise, and every 
means should be taken, by the use of cold baths, friction, and proper food, 
to tone up the vascular system. 

An efficient means of arresting the haemorrhage is compression of the 
nose between the thumb and finger. This may be combined with the 
application of ice over the root of the nose, and sometimes small pieces of 
ice may be introduced into the nostrils. The application of cold to the 
back of the neck or its use in the mouth may be of service by exciting 
reflex contraction of the capillary vessels. All tight clothing or bands 
about the neck should be loosened, and the patient kept quiet in the sit- 
ting posture. After the haemorrhage has ceased the child should not blow 



CATARRHAL SPASM OF THE LARYNX. 439 

his nose for some time. The use of the compound tincture of benzoin or 
lemon juice, diluted, or a weak astringent solution, like alum or tannic 
acid, will sometimes arrest haemorrhage which does not yield to cold or 
pressure. The insufflation of astringent powders often increases the haem- 
orrhage because of the sneezing excited. If bleeding continues in spite 
of all the above measures, the anterior nares should be plugged with 
styptic cotton, and if this does not control it, the posterior nares should 
be plugged. Usually very little effect is seen from drugs given internally, 
although in frequently recurring haemorrhages where no local cause can 
be discovered ergot should be given a trial in full doses. 

In severe cases of nasal haemorrhage recurring at short intervals with- 
out any apparent cause, ulcer of the septum should be suspected, and, if 
present, should be touched with chromic acid. 



CHAPTER II. 

DISEASES OF THE LARYNX. 

The characteristic feature of laryngeal disease in infants and young 
children is the association of muscular spasm with all forms of the inflam- 
mation. Often it is the laryngeal spasm, rather than the inflammation, 
which gives rise to the principal symptoms. This spasm is only one 
expression of the great reflex irritability of young children. 

CATARRHAL SPASM OF THE LARYNX. 

Synonyms : Spasmodic laryngitis, spasmodic croup, catarrhal croup (sometimes 
improperly called laryngismus stridulus). 

The term catarrhal spasm, first suggested, I think, by Goodhart, is 
fairly descriptive of this disease, which is characterized by a very mild 
degree of catarrhal inflammation associated with marked laryngeal spasm. 

Etiology. — It is not often seen during the first six months, but is fre- 
quent from this time up to the third year. After five years it is rare. It 
occurs in children who are well nourished, as well as in those who are 
cachectic. Certain children have a predisposition to such attacks; those 
who have had one attack are likely to have others. Heredity seems to 
have some influence in producing this susceptibility. Catarrhal Bpasm of 
the larynx is frequently associated with enlarged tonsils and adenoids of 
the pharynx, sometimes with elongated uvula. The exciting cause may 
be exposure to cold, an attack of indigestion, or constipation. 

Lesions.— The catarrhal inflammation of the larynx affects chiefly the 
parts above the cords; there is congestion and dryness and later Increased 
secretion of mucus. To this there is added a spasm of the muscles of the 



440 DISEASES OF THE RESPIRATORY SYSTEM. 

larynx, especially the adductors. There is no submucous infiltration, and 
no tendency to oedema glottidis. 

Symptoms. — The attack may be preceded for several hours by slight 
hoarseness, or by a nasal discharge. During the day the child may 
have appeared perfectly well. Usually there is heard during the evening a 
hollow, barking cough, at first infrequent and not severe. About midnight 
this is apt to increase in severity, and there is now difficulty in breathing. 
As soon as this becomes marked the child wakes, and presents the char- 
acteristic symptoms of an attack. In the mildest cases the dyspnoea is 
not sufficient to waken the child. In severe cases there is marked dyspnoea, 
especially on inspiration, and a loud stridor as the air is drawn through 
the narrowed opening of the glottis. This may often be heard even in an 
adjoining room. There is seen on inspiration deep recession of the supra- 
sternal fossa, the supraclavicular spaces, and the epigastrium ; also depres- 
sion of the intercostal spaces, and even of the walls of the chest. The 
terror of the child or any excitement increases the spasm and aggravates 
the dyspnoea. The distress is very great; the breathing usually slow and 
laboured ; the voice hoarse, but rarely lost ; the cough stridulous, hoarse, 
and metallic ; the pulse rapid ; the temperature normal or slightly ele- 
vated, rarely over 101° F. The child sits up and struggles for breath, its 
forehead covered with perspiration. There may be slight lividity of the 
finger-tips and of the lips, and sometimes considerable prostration. In 
the course of three or four hours the attack slowly wears away and the 
child falls asleep. During the following day, aside from slight hoarse- 
ness and occasional cough, the child is apparently well. Most of the cases 
are not so severe as this ; there are the croupy cough, hoarseness, and gen- 
eral discomfort, but not marked dyspnoea. On the second night there is a 
repetition of the experience of the first, usually quite as severe unless af- 
fected by treatment ; and on the third day a remission similar to that of 
the day previous. On the third night the attack, if it occurs at all, is 
generally a mild one. Slight hoarseness persists for several days, but 
otherwise the child is apparently well. Many children have such attacks 
every few weeks in the course of the cold season, the slightest exposure or 
an indiscretion in diet being sufficient to induce one. 

Prognosis. — This is good, the disease never, I think, proving fatal, al- 
though nothing is more alarming, at least to parents, than to witness for 
the first time one of these severe attacks of catarrhal croup. 

Diagnosis. — Catarrhal spasm may be confounded with laryngismus 
stridulus and with membranous croup. Laryngismus stridulus is a rare 
disease, and occurs only in infancy. In it we have not simply stridulous 
breathing, but periods of complete cessation of respiration. These may 
be repeated many times during the day, and may continue for weeks, 
being often complicated by carpo-pedal spasm, sometimes by general con- 
vulsions. 



CATARRHAL SPASM OF THE LARYNX. 441 

From me branous laryngitis, catarrhal spasm is distinguished by its 
sudden onset, the mildness of the symptoms of inflammation, the spas- 
modic character of the dyspnoea, and the daily remissions. The history 
of previous attacks will often aid in diagnosis. In case of doubt, a posi- 
tive diagnosis can often be made by allowing the child to inhale a little 
chloroform. This at once relieves dyspnoea due to spasm, while it has 
scarcely any effect upon that due to pseudo-membrane. 

Treatment. — The purpose of treatment during the attack is to pro- 
duce relaxation of the laryngeal spasm. This is accomplished by the use 
of emetics, steam, and hot fomentations over the larynx. A favourite 
emetic is a tablet triturate of antimony and ipecac, gr. y-i-g- each. To a 
child of two years, one tablet may be given every ten or fifteen minutes, 
until free vomiting occurs ; or a teaspoonful of the syrup of ipecac and 
fifteen drops of the wine of antimony at the same interval. When chil- 
dren do not vomit after two or three doses the antimony should not be re- 
peated, as it may produce serious depression. 

Emetics have a double value if the attack is due to indigestion. If 
there is constipation, an enema should be given. Following the free 
vomiting there is generally some improvement in the symptoms, but there 
may be a recurrence of the spasm unless other means are employed. To 
prevent this, antipyrine is one of the most useful drugs. Three grains may 
be given in divided doses to a child two years old. This may be repeated 
in four or five hours if necessary. Quite as much relief as that obtained 
from the drugs mentioned is seen from the use of steam inhalations. For 
this purpose the child should be placed in a closed tent, and steam intro- 
duced from a croup kettle (page 58). This may be used in conjunction 
with other measures, and continued as long as necessary. Poultices or hot 
fomentations over the larynx are often useful. In one case in which se- 
vere spasm had recurred for eight successive nights in spite of everything 
that was tried, the child being in great distress from the dyspnoea, I per- 
formed intubation, which gave instant relief. Tracheotomy, however, 
would scarcely be advisable. 

During the day following the first night attack, it is well to continue 
the antimony and ipecac in doses too small to produce vomiting— -1 
gr. T i_ each, every four hours. After 6 p. if. the doses should be 
doubled, and at bedtime two grains of antipyrine given. If 30 treated, 
the symptoms may not recur upon the second night, or there may be 
only the cough without the severe dyspnoea. The child should be con- 
fined to the house for two or three days after one of these attacks, the 
drugs being gradually reduced; but the antipyrine should he given at 
bedtime for three or four successive nights. 

To prevent a repetition of the attacks and remove the tendency to 
them, it is most important that the child should have plenty of fresh air 
and cold bathing, especially cold sponging about the neck and chest. 



442 DISEASES OP THE RESPIRATORY SYSTEM. 

Everything which experience has shown to bring on the attack should be 
carefully avoided. Local causes, such as adenoid growths, hypertrophied 
tonsils, elongated uvula, etc., should receive appropriate treatment. Gen- 
erally it is not necessary to exclude fresh air from the sleeping room. 
Although an open window for a single night may sometimes excite the 
attack, a persistence in this direction tends rather to diminish the sus- 
ceptibility. If the child's condition is poor, general tonic treatment is to 
be employed. 

ACUTE CATARRHAL LARYNGITIS. 

This is not nearly so frequent as the disease just described, although 
it is much more severe, and may even be fatal. It occurs especially in 
children from one to five years of age, usually in the cold season. Pre- 
disposition to attacks is induced by the same conditions as in the case of 
acute rhinitis. Catarrhal laryngitis may be primary, when it is usually 
excited by cold or exposure,* or it may be secondary to measles, influenza, 
scarlet fever, or other infectious diseases. It may also be of traumatic 
origin, from the inhalation of steam or irritating gases. 

Lesions. — There is a moderately intense congestion of the laryngeal 
mucous membrane, sometimes general and sometimes localized. This may 
be seen with the laryngoscope, but is not always visible after death. With 
the congestion there are swelling and dryness, followed by increased secre- 
tion. In the milder cases the process is limited to the mucosa. In the 
more severe cases it involves the submucosa also, which is congested, 
cedematous, and may be infiltrated with cells. The changes are especially 
marked in the lymphoid tissue of the subglottic region. The swelling 
may be sufficient to produce a very marked degree of laryngeal stenosis. 
In many mild and in all the severe cases there is associated catarrhal 
inflammation of the trachea, and often of the larger bronchi. In young 
children there is very little tendency to ced ema glottidis, so frequent a 
complication in adults. 

Symptoms. — In the mild form, such as that which is usually seen in 
older children, there are hoarseness, or even loss of voice, and a laryngeal 
cough which is sometimes hard and teasing, always worse at night. There 
may be pain and soreness over the larynx. Constitutional symptoms 
are mild or absent, the patient not usually being sick enough to go to bed, 
and often rebelling even at being kept indoors. The duration of the dis- 

* The following case is a good illustration of a severe attack excited by cold : A 
rather delicate infant, eight months old, an inmate of the New York Infant Asylum, 
was taken out on a raw December day with very slight covering. In a few hours 
hoarseness and stridor were noticed, and the temperature was 101° P. ; three hours 
later it was 103°, and in spite of the usual remedies which were employed the dyspnoea 
had reached such a degree as to require intubation. The tube was worn only three 
days and the case made a prompt recovery. 



ACUTE CATARRHAL LARYNGITIS. 443 

ease is from four to ten days, with a strong tendency to relapses from 
slight causes. 

The severe form of catarrhal laryngitis is sometimes preceded by acute 
coryza, or there may be mild laryngeal symptoms for a few days before the 
development of the more severe ones. In other cases the disease develops 
rapidly and severe symptoms are present within a few hours from the onset. 

When the case is fully developed the voice is metallic and hoarse, 
and occasionally but not usually lost. There is a hoarse, dry, barking 
cough, which is very distressing, and sometimes almost constant. The 
cough, like the voice, is stridulous, and more or less stridor is present on 
inspiration. There is a slight amount of constant dyspnoea, but this is 
scarcely noticeable unless the chest is bared. Severe dyspnoea occurs in 
paroxysms, usually at night. Then, we may get the signs of obstructive 
dyspnoea similar to those mentioned in severe attacks of catarrhal spasm. 
This dyspnoea is chiefly inspiratory, but in some cases it increases steadily 
from the beginning of the attack, and may be indistinguishable from that 
due to pseudo-membrane. Constitutional symptoms are usually present 
and may be severe. The temperature ranges in most cases from 101° to 
103° F., but may go to 104° or 105°. The pulse is rapid and full and res- 
piration is accelerated. Older children sometimes complain of pain in 
the larynx and trachea, increased by coughing. The symptoms are severe 
for two or even three days, the fever continuing with moderate prostra- 
tion and paroxysms of dyspnoea, sometimes even attacks of suffocation and 
cyanosis. Usually after two or three days there is a gradual subsidence 
of the dyspnoea and inflammatory symptoms, and the case goes on to re- 
covery. At other times the inflammation extends downward to the large 
and then to the small bronchi, and finally results in broncho-pneumonia. 
The attack may prove fatal from laryngeal obstruction due to swelling 
and spasm. 

Diagnosis. — This disease is chiefly to be distinguished from pseudo- 
membranous laryngitis. The onset of the two diseases may bo very similar, 
and for the first twelve hours we have no absolute means of distinguishing 
between them, except possibly by the use of the laryngoscope, which is 
often conclusive in older children but not usually so in infants. All cases, 
therefore, should be looked upon with a degree of apprehension. The 
temperature in the catarrhal is usually higher than in the membranous 
form. The dyspnoea is mainly paroxysmal, with daily remissions and 
nightly exacerbations, and is chiefly inspiratory, while that of membranous 
laryngitis is constant, steadily and often rapidly increasing, and i- presenl 
both on inspiration and expiration. In catarrhal laryngitis the v<>i.-. is 
not usually lost, but in the membranous form this is fche rule. There can 
be little room for doubt when there are enlarged glands, pseudo-mem- 
branous patches on the tonsils, nasal discharge, and albumin in the urine. 
Very of ten, however, all these evidences of diphtheria are wanting, the 



444 DISEASES OF THE RESPIRATORY SYSTEM. 

really difficult cases being those in which the process begins in the larynx. 
The prevalence of diphtheria and a known exposure count for something 
in favour of membranous laryngitis. If cultures from the pharynx show 
the presence of Loeffler bacilli, diphtheria of the larynx is highly prob- 
able ; but no conclusion can be drawn when cultures give negative results. 
In catarrhal as well as in membranous laryngitis there may be extreme 
dyspnoea, cyanosis, pallor, prostration, and even death. 

Prognosis. — This depends somewhat upon the cause of the disease and 
also upon the age of the patient. It is much worse when it is secondary 
to measles or scarlet fever. It is better in children over three years of age 
than in infants, also when the general condition of the child is good. The 
prognosis in severe catarrhal laryngitis should always be guarded, not only 
on its own account, but also because it is impossible to be certain that 
the case may not be one of pseudo-membranous laryngitis. 

Treatment. — In all cases children affected are to be kept in bed ; and 
the temperature of the room should be between 72° and 75° F. The diet 
should be light and fluid, and the bowels should be freely opened by calomel 
or a saline. A hot mustard foot bath should be given at the outset ; also, 
benefit may sometimes be derived from aconite, given in one-quarter- 
minim doses every fifteen minutes for the first five or six hours. An- 
tipyrine (two grains every four hours to a child two years old) is useful if 
there is much spasmodic dyspnoea. For this symptom emetics are bene- 
ficial, given as in catarrhal spasm. The use of ipecac and squills in smaller 
doses than is required for emesis (five drops each of the syrups of ipecac 
and squills every two hours) may give relief, especially in the early stage, 
when the cough is dry, hard, and severe. 

All the remedies mentioned are to be regarded as accessories to the 
essential treatment, which consists in the use of inhalations. The child 
should be placed in a tent (page 58) into which steam is introduced from 
a croup kettle or vapourizer. Simple steam may be used, or turpen- 
tine, limewater, or creosote may be added. In moderately severe cases 
inhalations should be used for fifteen minutes every two hours ; in very 
severe ones they should be continued the greater part of the time. Poul- 
tices or hot fomentations may be applied over the larynx. Belief is some- 
times obtained by using counter-irritation by a mustard paste, but blister- 
ing should never be allowed. In my experience the local use of cold is 
very unsatisfactory, on account of the difficulty of applying it properly, and 
the objection to it on the part of young children. Stimulants may be re- 
quired late in the disease, the amount of prostration being the guide to 
their use. 

In cases of extreme dyspnoea operative interference may be needed. It 
is required more often in infants and young children than in those who 
are older, and especially in the subglottic form of the disease. Opinions 
will of course differ as to when the dyspnoea has reached the danger point. 



PSEUDO-MEMBRANOUS LARYNGITIS. 445 

One should not wait for general cyanosis. If pallor, marked prostration, 
and steadily increasing dyspnoea are present the case should not be allowed 
to go on without interference. Intubation has, to my mind, every advantage 
over tracheotomy, and is always to be preferred in these cases. One should 
not hesitate to operate, even though he may be perfectly sure that the case 
is one of catarrhal inflammation only. The severity of the dyspnoea is the 
only guide, and more than once I have seen cases shown at autopsy to be 
catarrhal, which were regarded during life as undoubtedly membranous. 
If intubation is done, the tube can usually be dispensed with in two or 
three days. Convalescence is usually rapid, but there is danger of recurring 
attacks during the remainder of the cold season. 

PSEUDO-MEMBRANOUS LARYNGITIS. 

Synonyms : Membranous croup, true croup, laryngeal diphtheria. 

Bacteriology has settled many questions long debated with reference to 
this disease. For nearly half a century the identity of membranous croup 
and laryngeal diphtheria has been contended for by some observers, and 
denied by others equally good. The extensive bacteriological researches 
made since 1890, both in this country and in Europe, have yielded results 
sufficiently uniform to warrant the following statements : 

1. Pseudo-membranous inflammation beginning in the larynx is almost 
invariably true diphtheria — i. e., it is due to the Loeffler bacillus. 

2. Pseudo-membranous laryngitis following a primary pseudo-mem- 
branous inflammation of the tonsils, pharynx, or nose, is, in the great ma- 
jority of cases, due to the Loeffler bacillus. 

3. Pseudo-membranous laryngitis following pseudo-membranous in- 
flammation of the tonsils, nose, or pharynx, occurring as a complication 
of measles, scarlet fever, or influenza, is more frequently due to another 
kind of infection (usually the streptococcus) than to the Loeffler bacillus. 

The etiology, lesions, pathological relations, and bacteriological diag- 
nosis of pseudo-membranous laryngitis are considered in the chapter de- 
voted to Diphtheria. In the present chapter there will be considered only 
the clinical aspect of the cases, especially of those in which the disease 
begins in the larynx ; for even if the cause is in most cases diphtheria, the 
clinical picture is laryngitis. 

In cases of primary laryngeal diphtheria there are wanting mosi of the 
characteristic clinical features which distinguish diphtheria of the pharynx. 
There are two reasons for this : one is the relatively rapid course of the 
disease, often producing death from local causes before the constitutional 
symptoms resulting from the absorption of the toxine have developed ; 1 In- 
second reason is, that absorption of the poison by the laryngeal mucous 
membrane is very slow and feeble as compared with thai which takes place 
from the pharynx. Hence it follows that glandular enlargements, albumi- 



446 DISEASES OF THE RESPIRATORY SYSTEM. 

nuria, and asthenic symptoms are generally wanting ; also, that in the cases 
which come to autopsy early, the parenchymatous degenerations in the 
heart, kidney, and other organs are seldom found, but instead only such 
lesions as are connected with the laryngeal disease. The feeble contagion 
is due to the fact that the course is much shorter, and that the discharge 
from the nose and mouth is slight, or absent altogether. 

Symptoms. — In its onset, membranous inflammation of the larynx is 
indistinguishable from the catarrhal form. It is perhaps a trifle less 
abrupt, and apparently not quite so severe for the first twelve hours or 
even for a longer time. We have the same hoarse cough and voice, with a 
slight stridor, gradually increasing. The constitutional symptoms are 
usually not quite so marked, the temperature ranging from 99° to 101° 
F. The pulse is accelerated, but not weak or intermittent. It is the 
progress of the disease which indicates its character, usually during the 
first twenty-four hours. A child beginning in the morning with such 
symptoms as have been described, may by evening show a decided change 
for the worse, or the symptoms may increase with great rapidity during the 
night. At first the voice is hoarse ; later it is entirely lost. Dyspnoea in 
the beginning is scarcely noticeable, but steadily increases hour by hour. 
At times of excitement it may be very great, but as the spasm subsides it 
diminishes. During the second twenty-four hours all the symptoms are 
usually well developed. The respiration is often somewhat accelerated, 
but it may be slower than normal. The face is pale and anxious. The 
alae nasi dilate with each inspiration. The loud, " sawing," stridulous 
breathing is present. As the dyspnoea increases, all the accessory muscles 
of respiration are brought into action. There is now with every inspi- 
ration deep recession of the suprasternal fossa, the supraclavicular re- 
gions, and the epigastrium. The child tosses uneasily from side to side in 
its crib, at times struggling violently to get more air into the lungs. The 
pulse grows rapid and weaker. There is slight blueness of the finger nails 
and the lips ; the face is usually pale ; but later this too may be cyanotic. 
The skin is covered with clammy perspiration. On auscultating the 
chest, very rude respiratory sounds are heard, but no vesicular murmur. 
As the symptoms increase in severity the temperature usually rises gradu- 
ally, in some very severe cases at the rate of a degree an hour, until shortly 
before death it reaches 104° or even 106° F. Late in the disease the in- 
tellect becomes dull, the violent struggles for air cease, and the child passes 
into a condition of semi-stupor which gradually deepens until death occurs, 
which may be preceded by convulsions. 

Such is the usual course of the disease when unrelieved by treatment. 
Its progress is most rapid in infants, in whom death usually takes place in 
from thirty-six to forty-eight hours from the first symptoms. In older 
children the course is rather slower, and the attack may last from two 
days to a week, death occurring more frequently from bronchial croup or 



PSEUDO-MEMBRANOUS LARYNGITIS. 447 

pneumonia. These are indicated by continued high temperature, rapid 
respiration, cyanosis, and increased prostration. 

The course of the disease is not ahvays so regular. Occasionally for a 
week or more the symptoms are precisely like those of catarrhal laryngitis 
of moderate severity — hoarseness, laryngeal cough, little or no fever, and 
slight or occasional dyspnoea. Then there may be the sudden develop- 
ment of very severe symptoms, and death in a few hours. Great improve- 
ment may follow the dislodgment of the pseudo-membrane by vomiting 
or coughing, although in most cases it forms again. 

Prognosis. — The issue of every case of pseudo- membranous laryngitis 
is doubtful. The prognosis depends upon the age of the patient, the 
character of the epidemic, and very much upon the treatment. The mor- 
tality of cases not treated is about 90 per cent. 

Diagnosis. — The points by which membranous laryngitis is distin- 
guished from the catarrhal form have been considered in connection with 
the latter disease. It may be further confounded with retro-pharyngeal 
abscess, a foreign body in the larynx, and even with broncho-pneumonia. 
Inspection, or, better, digital exploration of the pharynx, usually makes 
the recognition of retro-pharyngeal abscess an easy matter. The mistake 
generally made is that of trusting entirely to the patient's objective symp- 
toms for a diagnosis. With a foreign body there is usually a history of a 
very sudden onset and violent paroxysmal dyspnoea, without fever. Bron- 
cho-pneumonia is easily distinguished by its higher temperature, its physi- 
cal signs, and the difference in the character of the dyspnoea. A mistake 
is hardly possible except when there is also present some degree of catarrhal 
laryngitis. In any of these conditions, if time is taken to obtain a care- 
ful history and to make even a moderately thorough examination of the 
throat and lungs, no mistake need be made. Yet such cases have often 
been operated upon by physicians anxious to give immediate relief to what 
they had hastily diagnosticated as membranous laryngitis. 

Treatment. — All cases of membranous laryngitis should be isolated like 
those of diphtheria of the pharynx. Every case of pseudo-membranous 
laryngitis should receive an injection of antitoxine upon a clinical diag- 
nosis without waiting for this to be confirmed by a bacteriological exami- 
nation. Nowhere else are the beneficial effects from antitoxine so evident 
and so striking as in these cases. That the serum, when properly used in 
the great majority of cases, prevents the spreading of diphtheritic mem- 
brane from the larynx to the lower air passages is now well established. 
For dosage and other details regarding the use of antitoxine the renin- is 
referred to the article on Diphtheria. 

Emetics, inhalations of steam, and solvents for the pseudo-membrane, 
although they all sometimes give relief, are now little used, and arc never 
to be relied upon alone. In fact, leaving out antitoxine and surgical opera- 
tion, the only therapeutic measure that can be said to be of much avail is 



448 



DISEASES OF THE RESPIRATORY SYSTEM. 



calomel fumigation. This is in no sense a substitute for antitoxine, but 
may be employed where circumstances make the use of antitoxine im- 
possible, and in the few cases of pseudo-membranous laryngitis due to 
streptococci. 

Calomel fumigations. — These were first advocated by Corbin, of Brook- 
lyn, in 1881, although they did not come into general use until about 
1891. The method consists in the vapourization of calomel in a confined 
space, the patient inhaling the fumes. For this purpose the child should 
be placed in a close tent (page 58), either sitting or lying down. A very 
simple arrangement for the purpose, and one that can be extemporized 
readily, is the following : A strip of tin, or any sheet metal two inches 
wide and ten or twelve inches long, is bent and placed across the top of a 
pot-de-chambre ; upon this is placed the calomel, and beneath it, so that 

the flame will come close to the tin, an alco- 
hol lamp. The lamp is then lighted and 
the apparatus placed beneath the tent. It 
should always be steadied by the hand of 
an attendant, otherwise there is danger of 
fire, as the lamp might be accidentally over- 
turned by the child's struggles. In Fig. 70 
is shown an apparatus which can be used 
with greater safety, as it is suspended by a 
wire. In a few moments the tent, which 
should be kept closed, is filled with the 
white fumes of the mercury. From ten to 
twenty minutes are required to vapourize 
the ordinary amount used, depending upon 
the size of the flame. It is well to have 
the child somewhat accustomed to the tent 
before the fumigation is begun ; also to 
cover the body, except the face, so as, to 
prevent any unnecessary exposure to the 
calomel fumes. The usual amount vapour- 
ized at once is ten or fifteen grains, and this is repeated every one, two, or 
three hours, according to the severity of the case. This amount is calcu- 
lated for a tent which covers a child's crib. If a much larger one is used 
more calomel will of course be required. In extreme cases as much as 
twenty grains every hour have been used for days. After the calomel has 
all been vapourized the tent should be opened and the room thoroughly 
aired. 

At times so much irritation is produced by the fumes that it may 
have the effect of increasing the dyspnoea. This may be due either to the 
fact that the calomel contains impurities, or that the vapour is too con- 
centrated. The concentration of the vapour depends on the size of the 




Fig. 70. — ErmolcPs apparatus for cal- 
omel fumigation. 

a, alcohol lamp ; d, plate on which 
calomel is placed ; e, wire loop for 
suspension". 



PSEUDO-MEMBRANOUS LARYNGITIS. 449 

tent and the rapidity of the process of vapourization. It is rare that any 
unpleasant symptoms occur. Nurses should always be warned against 
the danger of fire. I have several times known serious accidents from 
carelessness. Salivation in a patient is rare, but care is always neces- 
sary to prevent it on the part of the attendants. They should not put 
their heads beneath the tent ; the room should be kept as clean as pos- 
sible, and thoroughly aired after each fumigation. The mouth, gums, 
and teeth of the patient should be kept clean with a wash of chlorate of 
potash. 

The improvement is often very marked even after the first fumiga- 
tion, and nearly always after the second or third. Fumigations should be 
begun as soon as the diagnosis of membranous laryngitis is made, without 
waiting for even a moderate amount of dyspnoea. This applies both to 
cases beginning in the larynx and where the disease is secondary to phar- 
yngeal diphtheria. 

Operative measures. — Opinions will always differ as to the time when 
operative interference is called for. One should never wait for general 
cyanosis, for often this does not occur until just before death. It is better 
to operate too early than too late. After a fair trial has been made of 
other measures, and if, in spite of all, the dyspnoea increases steadily and 
the temperature begins to rise, operation should not be deferred longer. 
When this has been decided upon, the physician has the choice between 
intubation and tracheotomy. During the last ten years intubation has 
grown steadily in favour, and, since the introduction of antitoxine, trache- 
otomy has been practically abandoned as a primary operation for the re- 
lief of pseudo-membranous laryngitis, it being resorted to only in rare 
cases, after intubation has failed to give relief. 

The general treatment of the child is important, and should not be 
overlooked. It includes careful feeding, and the use of alcoholic stimu- 
lants according to the amount of prostration present. All patients with 
membranous laryngitis should be closely watched, for marked changes 
may take place in the course of a few hours. 

Results without antitoxine.—ln November, 1892, McNaughton and 
Maddren (Brooklyn), in response to a circular letter, collected statistics of 
8,383 cases of pseudo-membranous laryngitis, occurring in the practice of 
242 physicians. The following results were reported : Tracheotomy, 2,417 
cases; recoveries, 58G, or 24*2 per cent. Intubation, 5,546 cases; recov- 
eries, 1,091, or 30'5 per cent. 

In 1893, Ranke (Munich) published reports of 1,445 cases of intuba- 
tion, collected from various German hospitals, with ;>;>:; recoveries, or 38 
percent. Bokai (Buda-Pesth), in 500 operations, reports L80 recoveries, 
or 3G per cent. In all the different series of cases above referred to, the 
percentage of recoveries has ranged from 30 to 40. Combining them, we 
have 7,491 cases of intubation for membranous laryngitis, with 2,424 re- 
35 



450 DISEASES OF THE RESPIRATORY SYSTEM. 

coveries, an average of 32*3 per cent. These figures may be taken to rep- 
resent, as accurately as statistics can, the results from intubation prior to 
the use of calomel fumigations and before the introduction of antitoxine. 

With the introduction of calomel fumigations the statistics of the opera- 
tion from 1891 to 1895 were materially improved. Of the cases of intuba- 
tion collected by McNaughton and Maddren, only 85 had received calomel 
fumigations, with 35 -3 per cent recoveries. Although no large collection 
of cases so treated has been made, the experience of Dillon Brown may be 
taken as fairly representing the improvement in the results of intubation 
by the addition of calomel. Up to June, 1894, he reports his personal 
experience as follows : 490 intubations without calomel fumigations with 
34*8 per cent recoveries; 279 operations with calomel fumigations with 
49-4 per cent recoveries. Nearly all of the cases in both series were 
from private practice. In addition to this reduction of mortality in cases 
operated upon, it was a matter of common observation in New York and 
Brooklyn, that during the period mentioned a much larger number of 
cases than ever before recovered without operation. 

Such were the results in laryngeal diphtheria prior to the introduction 
of antitoxine in 1895. They have been fully given, that they may be com- 
pared with those obtained since that date with the addition of antitoxine. 
The latter figures are given in the general article on Diphtheria. 

INTUBATION. 

Intubation is the introduction of a tube through the mouth into the 
larynx for the relief of laryngeal dyspnoea. For the operation as now 
performed the world is indebted to Joseph O'Dwyer, of New York. 

A set of O'Dwyer's instruments (Fig. 71) consists of six gold- 
plated tubes, an introductor, an extractor, a mouth-gag, and a gauge. In 
his latest tubes the lower extremity is made somewhat bulbous, and not 
straight, as appears in the illustration. The operation is not very difficult, 
provided one has had previous practice on the cadaver. Without this it 
should not be attempted. The tube is selected according to the age of the 
patient, the length for the different years being indicated upon the gauge. 
The age is not the only guide, for a very large child will often require a 
tube of larger size than its age would indicate. 

Tlie introduction of the tube. — Two assistants are required, neither of 
whom need be skilled. The child is taken from the bed, wrapped in a 
large blanket, and held in a sitting position upon the lap of the first assist- 
ant, its head being inclined neither backward nor forward. The arms 
may be confined by the blanket or held by the assistant. The second as- 
sistant, standing behind the child, steadies the head, and with one finger 
holds the loop of braided silk with which the tube should be threaded. 
The tube is attached to the introductor, and the gag is inserted into the 
left angle of the mouth and opened as widely as possible. The slipping 



INTUBATION. 



451 



of the gag and laceration of the mouth may be prevented by using a piece 
of rubber tubing to cover each arm of the gag where it comes in contact 




Fig. 71. — O'Dwyer's intubation set. 
1, introductor ; 2, gag ; 3, extractor ; 4, gauge ; 5, tube. 

with the gum. The attempts at introduction must be made quickly, 
for during them respiration is practically arrested. Several short attempts 
are always better than a single prolonged one. Very little force is ordi- 
narily required in introducing the tube, that used in passing a catheter 
being a good general guide. In cases of subglottic stenosis, however, quite 
a little force may be necessary (Brown). 

The index finger of the left hand is used as a guide in introduction. 
This is passed well back into the pharynx, then brought forward until a 
hard nodule — the upper border of the cricoid cartilage — is encountered. 
This is the best of all landmarks, since the soft parts are often distorted 
by swelling. Directly in front of the cricoid cartilage may be tVlt the 
epiglottis and the opening of the larynx, which are readily recognised 
after the touch has become somewhat educated. The tube is passed along 
the palmar surface of the left index finger, by which it is guided into the 
larynx; it is then pushed off the introductor by a thumb-piece attached 
to its handle. When it is certain that the tube is in position, and the pa- 
tient breathes properly, the loop of silk attached fco the head of the tube 
is cut off and pulled through, the removal of the tube being prevented 
by placing the left forefinger upon its head. The silk should not be left 



452 DISEASES OF THE RESPIRATORY SYSTEM. 

attached unless there is evidence of loose membrane below the tube. It 
may then be fastened to the cheek by a piece of adhesive plaster. The 
tube is known to be in place, first, by the hissing breathing sounds, 
somewhat similar to what is heard when the trachea is opened ; secondly, 
by a severe paroxysm of coughing, which is usually excited by a tube 
in the larynx ; thirdly, by the relief of the dyspnoea. If this relief is not 
very apparent the physician may still be in doubt as to whether the tube 
is in the larynx or the oesophagus. If in the former, it can not be pushed 
down by the finger without depressing the larynx with it ; and by intro- 
ducing the finger into the pharynx, the posterior wall of the larynx can 
be felt between the finger and the tube. The most common mistake 
made is to pass the tube into the oesophagus. This sometimes happens 
because the position of the child's head is improper — too far forward or 
too far backward — but more often because the operator has not been quite 
sure of his landmarks. If this has occurred, there is no relief to the dysp- 
noea, no hissing sound, and the tube can be pushed down indefinitely. 
When this condition is recognised, the tube is withdrawn by the loop of 
silk and after a few moments a second attempt made. 

False passages in the larynx are most frequently made because the 
operator has worked at the angle of the mouth instead of keeping in the 
median line. The tube usually goes into one of the ventricles, and may 
be pushed quite through the larynx into the cellular tissue. This is not 
likely to happen unless undue force has been used. The production of 
a false passage is recognised by the fact that, although the tip of the tube 
can be felt to enter the larynx, it does not descend, but projects above 
the epiglottis. 

False membrane which has become loosened is sometimes crowded 
down by the tube and obstructs the larynx just below it. This is one of 
the most serious accidents that may occur, but fortunately it is not a 
frequent one. It is more liable to happen where the disease has existed 
for several days than in recent cases. The tube may be in place in the 
larynx as shown by all the signs above mentioned, except relief of the 
asphyxia. In such a case the immediate withdrawal of the tube is neces- 
sary ; it being often followed by the discharge of masses of loose mem- 
brane. This is aided by the administration of a teaspoonf ul of pure whis- 
key or brandy to excite a strong cough. Artificial respiration may be 
required, and if there is no relief by any of these means tracheotomy is 
indicated. Asphyxia is sometimes produced by prolonged and injudicious 
attempts at introduction. 

After-treatment. — So far as the tube itself is concerned no treatment 
is required. The original disease is to be treated as before. The operation 
has removed only one danger from the patient, viz., that of asphyxia from 
mechanical obstruction of the larynx. A good expulsive cough should 
occur after the tube is in place. This is necessary to clear the tube of 



INTUBATION. 453 

mucus, as the pharynx and larynx are generally filled with it as a result 
of the manipulation. 

The child should not be allowed to lie upon its face, nor should it be 
held over the nurse's shoulder face downward, for in either position a slight 
cough is enough to expel the tube. Nursing infants may continue at the 
breast after the operation ; ordinarily they have but little difficulty iu swal- 
lowing. Older children often experience considerable trouble in taking 
liquids. This may be overcome by the device suggested by Casselberry 
(Chicago), of having the patient's head lower than his body while he drinks. 
If there is still trouble in taking fluids, semi-solid articles, such as con- 
densed milk, wine jelly, corn starch, or scrambled eggs, may be tried. 
Feeding is always easier after the first day or two, and patients who wear 
a tube for chronic disease soon experience no trouble whatever, showing 
that the difficulty depends more upon the inability to co-ordinate the move- 
ments of the N muscles of deglutition when the tube is in place than upon 
mechanical causes, for the head of the tube is effectually covered by the 
epiglottis. 

It sometimes happens that the tube is coughed out soon after its 
introduction, because too small a size has been used. In some cases 
this occurs repeatedly. It happened in a case of my own twenty- 
eight times during four days. Such cases are probably due to paralysis 
of the laryngeal muscles. The dyspnoea does not usually return for 
two or three hours after the tube has been coughed out, so there is 
ample time to notify the physician. It may happen that the tube is 
coughed up and not seen by the nurse, or it may be coughed up and 
swallowed by the child. When called because of dyspnoea after operation, 
the physician should make a digital examination of the pharynx to be sure 
that the tube is still in place. Swallowing the tube generally causes no 
harm to the child, for tubes have repeatedly passed through the intes- 
tines. 

The entrance of food into the bronchi through the tube is a danger 
that does not exist, as has been shown by the extensive post-mortem obser- 
vations of Northrup in the New York Foundling Asylum. My own expe- 
rience in the New York Infant Asylum coincides in every particular with 
his statement, that the broncho-pneumonia following intubation does not 
depend upon the entrance of food into the bronchi. 

Ulceration at the head of the tube very rarely occurs, provided properly 
made tubes are employed.* The tube rests aot upon the vOcal cords, but 
upon the inferior ventricular bands. When ulceration occurs, it is usually 
of the anterior wall of the trachea, at the lower end of the tube, and 



* This and many other bad results obtained after intubation are due to improperly 

constructed instruments. Those made by (Jeorge Ermold, 312 Bast Twenty-second 
Street, New York, are perhaps the most reliable. 



454: DISEASES OP THE RESPIRATORY SYSTEM. 

appears to be produced by the movements of the tube during deglutition. 
With O'Dwyer's latest tubes there is much less liability of this occurring. 
The ulcers are usually small and superficial. Deep ulcers extending to 
the tracheal rings may be seen in ill-conditioned children, usually in con- 
nection with other complications severe enough to cause death. 

Spontaneous descent of the tube into the larynx is impossible, and it 
can not be crowded down without using considerable force and severely 
lacerating the larynx. 

Sudden blocking of the lower end of the tube by membrane loosened 
from the trachea or bronchi is an infrequent accident. The usual result 
of this is the immediate expulsion of the tube by coughing, the discharge 
of the loose membrane following. This condition is one of the safety valves 
of the operation. One of the strong points in favour of intubation is that 
the forcible cough which the patient is able to make on account of the 
narrow opening of the tube, often enables him to expel large accumula- 
tions of mucus, and even membrane, more readily than through a much 
larger tracheal opening. 

In membranous laryngitis the tube is usually left in place from four to 
seven days, longer in very young children. Should the tube be coughed 
out at any time, its introduction should be delayed until dyspnoea returns. 
If this happens on the third or fourth day, a second introduction is often 
unnecessary. 

The removal of the tube. — This is rather more difficult than its intro- 
duction. The general arrangement of the patient and assistants is the 
same as for introduction. The left index finger is placed upon the head 
of the tube, which is steadied externally by the thumb of the same 
hand. The beak of the extractor is introduced within the opening of the 
tube, its jaws are then separated by pressure upon the lever at the han- 
dle, and the instrument withdrawn, very slight force being required. 

The tube is first removed tentatively, the physician waiting to see if 
dyspnoea returns. It is well to give an opiate an hour before the removal 
of the tube, since the contact with the air almost invariably excites a 
marked degree of laryngeal spasm which lasts for ten or fifteen minutes. 
To avoid the production of vomiting and the entrance of food into the 
larynx, food should not be given for two hours previously. If dyspnoea 
does not return in the course of three or four hours, the probabilities are 
that the tube will no longer be required. It is very exceptional that the 
patient has great difficulty in dispensing with the tube, as so often hap- 
pens after tracheotomy. 

The advantages over tracheotomy. — The advantages claimed by 
O'Dwyer for this operation over tracheotomy are conceded by most of 
those who have had any considerable experience in the operation, viz. : 
(1) It is quicker, simpler, and adds no danger to the original disease ; (2) 
there is no shock or haemorrhage ; (3) no anaesthetic is required ; (4) no 



SUBMUCOUS LARYNGITIS. 455 

fresh wound is made which may prove an avenue of infection ; (5) it gives 
an opportunity for a better expulsive cough, which is of great value in 
dislodging false membrane and mucus ; (6) there are usually no objections 
on the part of the parents to be overcome — a point of great impor- 
tance ; (7) the air is warmed and moistened as it is normally, by passing 
over the nasal and buccal mucous membranes ; (8) no skilled after-treat- 
ment is required : as the largest proportion of the cases of diphtheria 
are among the very poor, living under conditions in which the careful 
after-treatment required in tracheotomy is difficult or impossible to ob- 
tain, this is an important point ; (9) in infancy, all who have had experi- 
ence with both operations admit the great superiority of intubation ; (10) 
the intubation tube can be dispensed with earlier than the tracheal can- 
ula, and also with much less difficulty ; (11) if tracheotomy is subse- 
quently required, the operation may be done upon the tube as a guide. 

The only objection of much force urged against intubation is that 
asphyxia may be produced by crowding down loose membrane into the 
larynx. This is a very infrequent accident ; should it happen, and the 
asphyxia not be relieved by coughing up the membrane, tracheotomy may 
be performed. 

Experience has clearly proved that intubation relieves the dyspnoea 
due to laryngeal stenosis promptly, efficiently, certainly ; it does this with- 
out many of the dangers and objectionable features of tracheotomy, while 
at the same time it does not deprive the patient of any essential advantage 
which tracheotomy affords. 

The use of antitoxine in the treatment of diphtheria has so shortened 
the period of stenosis that tracheotomy as a routine operation is hardly 
justifiable. The great superiority of intubation is now generally admitted 
not only in America, but all over the continent of Europe, where it has 
practically displaced the older operation. 

SUBMUCOUS LARYNGITIS— (EDEMA OF THE GLOTTIS. 

These two conditions are not quite identical, although they are close- 
ly associated and may be conveniently considered together. They are 
both rare in early life. In true oedema of the glottis there is simply a 
dropsical effusion into the submucous cellular tissue of the aryteno-epi- 
glottic folds, causing them, to project as large rounded swellings on either 
side of the superior isthmus of the larynx. They may be of sufficient size 
to cause serious or even fatal obstruction to respiration. With the laryn- 
goscope they appear as pale red tumours, lying usually in contacl near 
the base of the tongue. By the finger their presence can be quite as 
readily distinguished. (Edema of the glottis occurs principally in the 
late stages of nephritis. 

In the inflammatory form of oedema, or true submucous laryngitis, 
there is the same sort of swelling of these structures, hut in this case it is 



456 DISEASES OF THE RESPIRATORY SYSTEM. 

due to some active inflammation -in the neighbourhood. The swelling is 
partly from the oedema and partly from cell infiltration. Usually all the 
parts surrounding the upper opening of the larynx are in a state of acute 
inflammation. The epiglottis may be swollen to the thickness of a finger, 
and easily seen by depressing the tongue. 

The exciting causes may be the mechanical irritation of foreign bodies, 
the inhalation of steam or irritating gases, erysipelas of the neck, primary 
catarrhal laryngitis, or retro-pharyngeal abscess. 

The symptoms in both cases consist in great inspiratory dyspnoea 
with attacks of suffocation, while expiration may be quite easy. In true 
oedema there are in addition the symptoms of the original disease. In 
the inflammatory form there are the evidences of local inflammation — 
hoarseness, cough, pain, and difficulty in swallowing. A positive diag- 
nosis may be made by a digital examination. The symptoms develop with 
great rapidity in either variety, and frequently prove fatal in a few hours. 

The treatment of true oedema consists in scarification or multiple 
puncture, the application of ice externally, and even the swallowing of 
ice ; in the inflammatory form, in addition, local blood-letting by leeches 
and, as a last resort, tracheotomy. Intubation is useless in either form. 



CHRONIC LARYNGITIS. 

The following varieties are seen : (1) a simple form usually associated 
with adenoid vegetations of the pharynx ; (2) tubercular ; (3) syphilitic ; 
(4) that associated with new growths. 

1. With Adenoid Vegetations of the Pharynx. — This is not very uncom- 
mon. The larynx is kept in a state of chronic congestion by the adenoid 
growth, and there finally develops a slight superficial catarrhal inflamma- 
tion. The symptoms may continue for many months. These cases are 
often treated for a long time unsuccessfully by the use of sprays, inhala- 
tions, etc., but the symptoms disappear rapidly after the removal of ,the 
adenoid growth. Similar symptoms may be associated with hypertrophic 
rhinitis. In this also the treatment should be directed to the primary 
condition. 

2. Tubercular Laryngitis. — This belongs to later childhood, and is rare 
even then. In infancy it is almost unknown. Eheindorf * has reported 
a case in a child of thirteen months, which was regarded during life as 
syphilitic, but was shown by autopsy to be tubercular. Of sixteen cases 
in children, reported by Rilliet and Barthez, none occurred during the 
first three years, and only four before the seventh year. The larynx alone 
may be affected, or the larynx and trachea, or the larynx, trachea, and 
lungs. Pulmonary tuberculosis is usually found to be present at autopsy, 

* Jahrbuch fur Kinderh., Bd. xxxiii, p. 71. 



CHRONIC LARYNGITIS. 457 

even though there may have been no pulmonary symptoms. Demme has 
reported a case of tubercular laryngitis in a boy of four years, whose 
lungs were healthy, death resulting from tubercular meningitis. 

The symptoms are hoarseness, aphonia, laryngeal cough, and muco- 
purulent, sometimes bloody, expectoration. The sputum may contain 
tubercle bacilli. With the laryngoscope tubercular deposits may be seen, 
but more frequently tubercular ulceration of the mucous membrane. In 
children this is usually superficial, the deep destructive ulceration seen in 
adults being very rare. 

It is to be differentiated from syphilis chiefly by the general symptoms, 
as the laryngoscopic appearances may be very similar. The treatment con- 
sists in keeping the ulcers as clean as possible by the use of sprays and 
the local application of astringent powders, like nitrate of silver and sul- 
phate of zinc or iodoform. 

3. Syphilitic Laryngitis. — In the early stage of syphilis the larynx is 
often the seat of a catarrhal inflammation, which presents nothing espe- 
cially characteristic except its protracted course. The laryngitis of late 
hereditary syphilis is quite rare, and is liable to be overlooked because of 
the difficulties in the way of a thorough examination, and because the dis- 
ease is usually painless. 

Strauss * has collected fourteen cases between the ages of three and 
fifteen years, and added three of his own. He states that deep-seated pro- 
cesses are much more rare than among adults. The parts most frequently 
affected are, first, the epiglottis ; secondly, the aryteno-epiglottic folds ; 
thirdly, the posterior laryngeal wall. The epiglottis was involved in 
twelve of fourteen cases. Usually there was only perichondritis ; in the 
more severe cases there was partial or complete destruction of the cartilage. 
In four cases papillomatous masses were seen. In five cases the process 
extended from the epiglottis to the epiglottic folds of one or both sides. 
In several instances the superior vocal cords were thickened from hyper- 
plasia, and occasionally small tumours were formed. In only one case was 
there ulceration of these folds. Changes in the vocal cords and the aryte- 
noid cartilages were rare, occurring only with extensive inflammation. 
The symptoms are those of chronic laryngitis; hoarseness, sometimes 
aphonia, and in a few cases chronic laryngeal stenosis. The diagnosis 
can be made only by means of the laryngoscope. In most of the cases 
there are present ulcerations of the palate or uvula, or scars from pre- 
vious ulcers; sometimes the disease extends into the nose. Serious 
symptoms often result when to old syphilitic lesions there is added acute 
laryngitis or oedema. 

In addition to the usual constitutional remedies for tertiary syphilis, 
and to the means ordinarily employed for the relief of chronic laryngitis, 

* Archiv fur Kinderh., Bd. xiii. 



458 ' DISEASES OF THE RESPIRATORY SYSTEM. 

intubation may be required in these cases for the relief of laryngeal ste- 
nosis. Nowhere are its advantages over tracheotomy more striking than 
here. The tube must usually be worn for many months. 



NEW GROWTHS. 

New growths of the larynx are not very rare in children. Excluding 
the granulations which follow the use of the tracheal canula, the only one 
that is likely to be met with is papilloma. This may occur even in in- 
fancy. According to Rauchfuss, the majority of the cases begin during 
the first year. Boys are more frequently affected than girls. 

The symptoms depend upon the size and location of the tumour. The 
earlier manifestations are usually ascribed to chronic laryngitis. There 
is hoarseness, sometimes loss of voice, and a paroxysmal cough ; later, 
dyspnoea develops. The symptoms are slowly progressive, and it may be 
several months before they are sufficiently severe to attract special atten- 
tion. A positive diagnosis is made only by the laryngoscope. There is 
seen a whitish granular tumour, sometimes pedunculated, sometimes with 
a broad base, attached to any part of the larynx. 

The treatment of these cases belongs to the specialist. Small pedun- 
culated growths may be removed through the mouth by means of the 
forceps or snare. Larger ones require thyrotomy. The prognosis is gen- 
erally unfavourable, on account of the danger of recurrence after opera- 
tion. Operative measures may be followed by bronchitis or broncho- 
pneumonia. 

FOREIGN BODIES IN THE LARYNX. 

The aspiration of foreign substances into the larynx is not a very rare 
accident in children. It usually happens from an attempt to cough, 
laugh, or cry while the child has something in its month. If the body is 
sharp and irregular, like a pin, the shell of a nut, or a fragment of bone, 
it is liable to become impacted in the larynx. If smooth, like a pea or 
a bead, it is usually drawn into one of the bronchi, generally the right. 

When the body enters the larynx there is immediately excited a violent 
paroxysmal cough, with dyspnoea amounting almost to suffocation. Often 
the body is dislodged by this initial attack of coughing. If it becomes 
impacted in the larynx, it may cause sudden death by occluding the 
glottis ; elsewhere it may excite acute laryngitis, usually of considerable 
severity. 

The impaction of a foreign body in one of the primary bronchi, or one 
of the lobar divisions, is indicated by cough and a severe localized pain in 
the chest. There may be expectoration of blood. On auscultating the 
chest, there is found an absence of respiratory murmur over one lung or 
one lobe, according to the situation of the foreign body. Percussion gives 



THE LUNGS IN INFANCY AND CHILDHOOD. 459 

increased resonance, which may even be tympanitic, owing to emphysema 
which rapidly develops. If the foreign body remains impacted in one of 
the bronchi, it usually excites a localized inflammation, which extends to 
the surrounding lung and terminates in the formation of an abscess. 
This may result fatally, or there may follow a prolonged illness, with 
hectic symptoms resembling pulmonary tuberculosis ; and finally, after 
weeks or months, the foreign body may be expelled by an attack of cough- 
ing, and the patient recover completely. 

The diagnosis of a foreign body in the larynx is made by the sudden- 
ness of the attack and the violence of the early symptoms. In older chil- 
dren the body may be seen with the laryngoscope, but in young children 
this is very difficult. The prognosis is always doubtful, and depends upon 
the nature of the foreign body and the point at which it has been arrested. 

Treatment. — The first thing to be tried is inversion of the patient. 
By this means, assisted by the cough, the foreign body is not infrequently 
expelled, even though it has passed below the larynx. The symptoms of 
laryngeal obstruction may call for immediate tracheotomy or laryngotomy, 
intubation not being applicable to these cases. If, after tracheotomy, the 
foreign body can be located in the larynx, but can not be extracted through 
the tracheal wound, the thyroid cartilage should be divided in the median 
line. The removal of a foreign body from the bronchi or the tracheal 
bifurcation should be attempted only by a skilled surgeon. 



CHAPTER III. 
DISEASES OF THE LUNGS. 

THE PECULIARITIES OF THE LUNGS IN INFANCY AND EARLY 

CHILDHOOD. 

Thorax. — The general shape of the thorax is somewhat cylindrical, 
the conical or dome-shape of the adult not being attained until puberty. 
The antero-posterior and the transverse diameters are nearly equal in the 
newly-born, but after the third year the transverse diameter is always 
greater, the difference increasing steadily up to adult life. On account of 
the shape of the chest, the lungs are situated rather more posteriorly in 
the infant than in the adult. 

The thoracic walls are very elastic and yielding, owing to the carti- 
laginous condition of a large part of the framework. They are rela- 
tively thinner than in the adult, chiefly owing to the imperfect develop- 
ment of the thoracic muscles. The greater pari of the thickness of the 
thoracic walls is due to the deposit of fat, generally abundant in well- 
nourished infants; but where the fat is scanty the walls are extremely 



460 DISEASES OF THE RESPIRATORY SYSTEM. 

thin. The capacity of the thorax is considerably encroached upon by the 
high position of the diaphragm, the large size of the thymus gland, and 
the frequent distention of the stomach and intestines. 

Respiration. — According to Uffelmann, the rapidity of respiration dur- 
ing sleep at the different ages is as follows : 

At birth 35 per minute. 

At the end of the first year 27 " " . 

At two years 25 " " 

At six years 22 " " 

At twelve years 20 " " 

During waking hours this rate is very materially increased, and from com- 
paratively slight disturbance it may be nearly twice as rapid. 

The type of respiration in infants is diaphragmatic, and it continues to 
be chiefly so until after the seventh year, w T hen the costal element grad- 
ually becomes more and more prominent. The rhythm of respiration is 
easily disturbed. In very young infants the regular rhythm is seen only 
in sleep. The lungs do not always expand equally ; at certain times and 
in certain positions respiration may be carried on for a few moments 
almost entirely with one lung. For some moments it may be very super- 
ficial, and then quite deep. The length of the interval between inspira- 
tion and expiration varies much at different times. Kegular rhythmical 
respiration is not fully established before the end of the second year. 
After this time disturbances of rhythm are chiefly due to pulmonary or 
cerebral disease ; but in infancy quite marked irregularity may have little 
or no significance. It is very common in all asthenic conditions. 

Structure. — As compared with the adult, the trachea of the young 
child is larger ; the bronchi are larger, more numerous, and occupy a 
greater space ; the air cells are much smaller and occupy less space ; and 
the interstitial tissue is much more abundant (Delafield). 

Physical Examination. — This requires tact and time, but yields results 
which are quite as satisfactory as in adults. It should be undertaken only 
in a room having a temperature of about 72° F., or before an open fire. 

Inspection. — This should be made with the chest bare. There should 
be noted the shape of the chest, the presence of deformities from rickets, 
the want of symmetry in the two sides, bulging of the intercostal spaces, 
whether the two lungs expand equally or not, also variations in rhythm, 
and the presence and extent of any recession of the soft parts or bony 
walls as an indication of obstructive dyspnoea. 

Palpation. — This also should be made upon the bare skin, always with 
the hand well warmed. Although we can not get the fremitus of the 
voice, we can get that of the cry. This is usually more intense than in 
adults, on account of the thinness of the chest walls. We frequently get 
a bronchial fremitus — a vibration produced by mucus in the tubes. This 
may enable one to recognise bronchitis quite as positively as by the ear. 



THE LUNGS IN INFANCY AND CHILDHOOD. 461 

The position of the apex beat of the heart should be determined, it being 
remembered that in infancy this is normally in the mammary line, or just 
outside of it, and usually in the fourth intercostal space. 

Percussion. — For the examination of the back, the child may be laid 
face downward upon the nurse's lap, or be seated upon her arm. For the 
front and the lateral regions of the chest, the child is most conveniently 
placed upon its side across a hard pillow. The percussion blow must be 
light, either with a single finger or a small percussion hammer, using a 
finger of the opposite hand as a pleximeter. Percussion should be made 
both during inspiration and expiration. The normal percussion note is 
somewhat tympanitic, this being due to the relatively large bronchi and 
the thin chest walls. This note is exaggerated in the interscapular region 
and beneath the clavicle, especially upon the right side. Here cracked- 
pot resonance may be obtained even in health. In early infancy the 
thymus gives dulness over the sternum as low as the third rib, sometimes 
even below this point, this gradually diminishing as age advances. 

Auscultation. — This may be practised with the naked ear or with the 
stethoscope. A stethoscope is absolutely necessary for a thorough exam- 
ination of the apices of the lungs in front and in the axillary regions. 
Most children are less frightened by the instrument than by the head of 
the physician during anterior auscultation. For the posterior part of the 
lungs, the stethoscope may be dispensed with. One with a small bell 
from half to three fourths of an inch in diameter is of great advantage. 
In auscultating with the ear it is not necessary to bare the skin. The 
physician should always auscultate the posterior part of the chest first, 
because he is most likely to find signs of disease there, and also because 
this is not so apt to frighten the infant. Every part of the chest should, 
however, be thoroughly auscultated, not omitting the high axillary regions. 
A convenient position for posterior auscultation is to have the child held 
over the nurse's shoulder. 

The normal respiratory murmur of the infant is generally described as 
puerile. In quality this has been likened to the bronchial breathing of 
the adult, but the resemblance is not a very close one. It is rude, rather 
loud, and seems very near the ear. Its peculiar character is due to the 
fact that the tracheal and bronchial sounds are more distinct, because 
not transmitted through so thick a layer of lung and chest wall. It is 
especially loud in the regions where the bronchi are superficial, as between 
the shoulder-blades and beneath the clavicles, particularly of the right 
side. A careful comparison of the two sides of the chest will generally 
enable an observer to avoid errors. The irregularity of rhythm which 
occurs from slight causes should be remembered, and the infant's position 
changed several times during auscultation, to avoid the mistake of at- 
taching too much importance to a feeble respiratory murmur of one side. 

On account of the thinness of the chest walls, their is always great 



462 DISEASES OF THE RESPIRATORY SYSTEM. 

difficulty in distinguishing between rales produced in the bronchi and 
pleuritic friction sounds. Before drawing any inference from the auscul- 
tatory signs, both lungs must be examined for several minutes, changing 
the child's position, and often inducing a cry or compelling a deep inspi- 
ration by other means, in order to bring out signs which otherwise may 
be overlooked. As auscultation is extremely difficult or impossible in a 
crying infant, this part of the physical examination should first be made 
if the child be quiet, since upon it we must chiefly depend for diagnosis. 
'Inspection and percussion can be deferred until later. 

Peculiarities in Disease. — There are several peculiarities connected 
with the respiratory organs in infancy and early childhood which must be 
constantly borne in mind in studying their diseases. The muscular de- 
velopment of the thoracic wall is feeble. The soft, yielding character of 
the thoracic framework causes the chest to sink in readily from atmos- 
pheric pressure whenever there is obstructive dyspnoea. On account of 
the small size of the air vesicles, acute congestion may interfere with their 
function almost as completely as does consolidation. Because of the 
delicate walls of the air vesicles, emphysema is readily produced in ob- 
structive dyspnoea, but it is rarely permanent. There is a tendency to 
collapse, either on the part of lobules or groups of lobules, but very 
rarely of an entire lobe. This is a much less important factor in the 
production of symptoms in acute pulmonary disease than many writers 
would lead us to suppose. The tendency of inflammation to spread 
from the large to the small bronchi is very much greater than in adults. 
In all forms of pulmonary disease the rapidity of respiration is much 
greater than in adults, on account of the rapid metabolism of the child. 
Areas of consolidation often exist without appreciable changes in the 
percussion note, because they are superficial and are surrounded by 
healthy or emphysematous lung. Flatness should always suggest the 
presence of fluid. Disease is often overlooked, from a failure to examine 
the whole chest. 

Probably the most common mistakes are to confound bronchial rales 
with friction sounds, exaggerated puerile breathing with bronchial breath- 
ing, and to overlook the existence of fluid because of the presence of 
bronchial breathing. 

ACUTE CATARRHAL BRONCHITIS. 

Acute catarrhal bronchitis is one of the most frequent conditions for 
which the physician is called upon to prescribe in children. It occurs at 
all ages, from early infancy up to puberty. Its frequency, however, di- 
minishes steadily after the second year. The predisposition to acute 
bronchitis exists with the same constitutional conditions, and is acquired 
in the same manner as the predisposition to. the acute catarrhal inflam- 
mations of the upper respiratory tract. (See Acute Rhinitis). Bronchitis is 



ACUTE CATARRHAL BRONCHITIS. 463 

very common in children who are suffering from rickets and malnutrition. 
It is much more frequent in the cold months, especially in the late winter 
and early spring, when there are sudden atmospheric changes and high 
winds. 

Bronchitis may be a primary or a secondary disease. The primary form 
is excited by cold, exposure with insufficient clothing in severe weather, 
wetting of the feet, or chilling of the surface in any manner. Under 
these conditions it may occur alone, or be associated with or preceded 
by acute catarrh of the nose, pharynx, or larynx. In rare cases it is 
caused by the inhalation of irritants. Bronchitis is an almost invariable 
accompaniment of measles and influenza. It is very common in pertussis, 
in scarlet and typhoid fevers and diphtheria, and may occur in any acute 
infectious disease ; it also complicates pneumonia and pleurisy. The rela- 
tion of micro-organisms to the other etiological factors is the same as in 
the other acute catarrhs. (See Rhinitis). 

Lesions. — Acute catarrhal bronchitis is an inflammation of the mucous 
membrane of the bronchi. As a rule it is bilateral, both sides being 
involved to the same degree. Localized bronchitis is secondary to some 
other pathological process in the lungs, usually tuberculosis or pneumonia. 
In acute bronchitis only the larger tubes may be affected, this usually 
being complicated with inflammation of the trachea (ordinary tracheo- 
bronchitis) ; or, in addition, the j^rocess may extend to the medium-sized 
tubes (severe bronchitis) ; or, in infants especially, it may extend to the 
smallest tubes (capillary bronchitis). In the last form there are invaria- 
bly changes in the zones of air vesicles surrounding the bronchi, and these 
cases are therefore more properly classed as broncho-pneumonia. In the 
first form the inflammation is superficial, and affects only the mucous 
membrane of the bronchi. In the second form it may involve the entire 
thickness of the bronchial wall, and in the third form it does so regularly. 

The pathological changes consist in congestion and swelling of the 
mucous membrane, desquamation of the epithelium, and an exudation of 
mucus and pus-cells. At autopsy the injection of the mucous membrane 
is usually distinct; pus and mucus line the walls of the larger bronchi, 
and by pressure ooze from the cut extremities of the smaller tubes. The 
chief lesion of the walls of the bronchi consists in an infiltration with leu- 
cocytes. In infants dying from bronchitis, the lungs are much more fre- 
quently emphysematous than collapsed. There is swelling of the lymph 
glands at the root of the lung, which in most of the acute cases is Blight, 
but in protracted cases, and after recurring attacks, may be quite marked. 

Symptoms. — It is convenient to consider separately the symptoms in 
infants and in older children. 

The bronchitis of infants.— 1. The mild form (bronchitis of the larger 
tubes). The onset is generally gradual, and the symptoms of bronchitis 
may be preceded by those of catarrh of the nose, pharynx, or larynx. The 



464 DISEASES OF THE RESPIRATORY SYSTEM. 

change in the character of the cough, the slightly accelerated breathing, 
and a further rise in temperature, indicate an extension to the bronchi. 
The cough may be constant and severe, or very slight. There is no ex- 
pectoration. The secretions are usually coughed up into the mouth or 
pharynx, and swallowed. This sometimes excites vomiting. At other 
times the mucus is coughed only into the trachea or larynx, and aspirated 
again into the lungs. The respirations are from 40 to 50 a minute, and 
often accompanied by a rattling sound, due to mucus in the large bron- 
chi or trachea. The general symptoms are not severe, and unless the in- 
fant is very young or very delicate no apprehension need be felt as to the 
outcome. The temperature is generally from 100° to 102° F. for two or 
three days, then below 100° F. There are a moderate amount of restless- 
ness dependent upon the severity of the cough, usually anorexia, and 
sometimes vomiting and diarrhoea. 

The physical signs in the first stage are dry, sonorous rales over the 
whole chest. A little later these give place to coarse mucous rales heard 
everywhere, but especially distinct between the scapulas and in the infra- 
clavicular regions. On palpation there is usually a marked bronchial 
fremitus. Often there is not enough dyspnoea to cause recession of the 
soft parts of the chest. Unless the disease extends to the smaller bronchi 
and the air vesicles, the illness usually lasts about a week. Coarse rales 
in the chest may remain for some time after the symptoms have subsided. 
Eelapses are exceedingly common. In a delicate or susceptible child, or in 
one whose surroundings are bad, one attack is likely to be followed by a 
succession of others, so that the child may not be really well until warm 
weather comes. The general health may suffer from the prolonged con- 
finement to the house, although the patient may never have been seri- 
ously ill. 

2. The severe form (bronchitis of the smaller tubes). This differs 
from the preceding variety mainly in the greater severity of all its symp- 
toms. The onset may be like that just described, the severe symptoms not 
appearing until the patient has been sick two or three days, or they may 
be severe from the outset. If the latter, it is indistinguishable from that 
of broncho-pneumonia. There are cough, dyspnoea, accelerated breathing, 
fever, and moderate, sometimes severe, prostration. The cough is tighter, 
and more frequently of a short, teasing character than severe and paroxys- 
mal. There is difficulty in nursing. Dyspnoea may be quite marked and 
is shown by the active dilatation of the alae nasi and the recession of all the 
soft parts of the chest on inspiration. The respirations as a rule are from 
50 to 80 a minute. The temperature for the first day or two is usually 
10.1° or 102°, but it may be 103° or 104° F. So high a temperature does 
not continue unless pneumonia develops. The prostration is in most cases 
more closely related to the dyspnoea and the rapidity of respiration than 
to the temperature. Often there is slight cyanosis. 



ACUTE CATARRHAL BRONCHITIS. 465 

In the beginning the chest is filled with sibilant and sonorous rales, 
many of them of a musical character. In twelve or twenty-four hours 
these are replaced by moist rales — coarse or fine, according as they are 
produced in the large or medium-sized tubes. There are often loud, 
wheezing rales on expiration. The respiratory murmur is feeble ; the 
resonance on percussion is normal or slightly exaggerated. As the case 
progresses toward recovery, the finer rales are the first to disappear. The 
rales are always best heard behind, but they are present all over the chest. 

At the onset of such a case it is impossible to say whether the disease 
will be limited to the medium-sized bronchi or will extend to the smallest 
bronchi and air vesicles. In young or very delicate infants, and during 
measles, it is very common for the disease to spread rapidly to the air vesi- 
cles. In other cases, usually in infants under six months old, there may 
develop attacks of respiratory failure or suffocation. These may occur in a 
severe case at any time, and, because of the infant's inability to empty the 
tubes of secretion, the dyspnoea steadily increases until the respiratory mus- 
cles are exhausted, the inspiratory force being too feeble to overcome the 
obstruction in the tubes. The symptoms which follow are usually ascribed 
to pulmonary collapse. I am, however, by no means certain that this is the 
correct explanation, for in autopsies made in such cases I have usually 
found the lungs to be the seat of acute emphysema. The clinical picture is 
a clear one. There is no disposition to cough or cry ; the pulse is feeble ; 
the respiration very rapid, superficial, often irregular ; the skin cyanotic, 
and often clammy. Finally, there may be added to the others signs of car- 
bonic-acid poisoning — dulness, apathy, and stupor. Such attacks may 
come on quite suddenly even in robust infants, and unless the treatment 
is energetic, even heroic, death often follows in a few hours, being fre- 
quently preceded by convulsions. 

The usual course of the disease in infants previously in good health 
is that the severe symptoms continue for two or three days only, after 
which the temperature falls to 100° or 100-5° F., and gradually becomes 
normal. .The constitutional symptoms usually decline with the tempera- 
ture, and, except during the first thirty-six hours, they rarely give cause 
for anxiety. Recovery almost invariably occurs unless the disease ex- 
tends to the finer bronchi. 

Bronchitis is principally to be distinguished from broncho-pneumonia. 
The differential diagnosis is more fully considered under I ha' disease. The 
most important points are that in pneumonia the temperature is higher 
and more prolonged, the prostration greater, the rales very often localized 
— being heard only behind, often over only one Lung — the duration is 
more protracted, and all the symptoms are more seven-. 

The bronchitis of older children. — This is not nearly so serious as in 
infants, because the same danger does not exist of extension of the inflam- 
mation to the finer bronchi and air cells. 
86 



466 DISEASES OF THE RESPIRATORY SYSTEM. 

1. The mild form. This is very common. The constitutional symp- 
toms are slight, and often entirely absent after the first day. The patient 
is never sick enough to go to bed. The first symptoms are cough and 
soreness or a sense of oppression beneath the sternum. The cough is 
always worse at night. It is at first tight, hard, and racking ; later it is 
loose, and in children over five years old there is usually expectoration — 
first of white, frothy mucus, but after a few days it becomes more abun- 
dant, and of a yellow or yellowish-green colour, from the presence of pus. 
The physical signs are only coarse rales, at first dry, and later moist, but 
heard over both sides of the chest, in front and behind. There may be 
some disturbance of digestion, anorexia, constipation, or diarrhoea. The 
usual duration of the attack is from one to two weeks. If the patient is 
not kept indoors the disease may pass into a subacute form, lasting for 
several weeks as a protracted " winter cough," but without any other im- 
portant symptoms. 

2. The severe form. The onset is abrupt, with fever, chill, pains in 
the back, headache, cough, and sometimes pain in the chest. There is a 
feeling of tightness or constriction beneath the sternum. The onset re- 
sembles pneumonia, except that the symptoms are less severe. The tem- 
perature for the first two or three days ranges between 100° and 103° F. 
It is generally highest in the first twenty-four hours. The cough resem- 
bles that of the mild form, but it is usually more severe. The expec- 
toration is more profuse, and occasionally, in the early stage, it may be 
streaked with blood. 

The coarse rales of the mild form are present, and in addition there 
are finer rales — at first dry, and later moist — heard all over the chest. Fre- 
quently, wheezing rales are heard on expiration. The duration of the at- 
tack is ordinarily from two to three weeks, the patient being sick enough 
to be confined to bed for three or four days only. There is frequently 
a cough for some time after all physical signs have disappeared. Relapses 
are easily excited by any indiscretion before the patient has quite recovered. 

The prognosis in the primary cases is good, such almost invariably ter- 
minating in recovery, and very exceptionally passing into broncho-pneu- 
monia; but this not infrequently happens when the attack complicates 
measles or pertussis. 

Treatment of Bronchitis. Prophylaxis. — To remove the predisposition 
to bronchitis the same means should be employed as those mentioned 
in acute rhinitis (page 430). General measures also should be adopted 
to build up the health of delicate infants. Those with tubercular 
antecedents, and those who are especially prone to pulmonary disease, 
should if possible spend the winter in a warm climate. In all such pa- 
tients the systematic administration of cod-liver oil should be continued 
throughout every cold season. The sleeping apartments of susceptible 
infants should not be too cold — never below '60° P. — but they must be 



ACUTE CATARRHAL BRONCHITIS. 467 

well ventilated, best by an open fire. Such children should sleep in flan- 
nel night clothes, care being taken to see that the feet are always warm. 
While bronchitis of the large tubes is not per se a serious disease, it may 
become so by extension to the smaller tubes. It is consequently very im- 
portant in infants and young children that these apparently mild attacks 
should not be neglected. 

General management. — Every young child who has an acute catarrh of 
the nose, pharynx, larynx, or bronchi should be kept indoors. In every 
such catarrh accompanied by fever the child should be kept in bed while 
the fever lasts, even if the temperature does not go above 100-5° F., and is 
accompanied by no other constitutional symptoms. In infants and young 
children, many cases of bronchitis result from an extension of an acute 
rhinitis or laryngitis, hence this precaution is of more importance than 
everything else in preventing the extension downward of a catarrhal in- 
flammation. A very large number of the cases will recover promptly when 
no other treatment is employed than to keep the child in bed. The tem- 
perature of the room should be about 70° or 72° F. It should be well 
ventilated and frequently aired, the child being removed to another room 
while this is done. Infants should not be allowed to lie for hours in the 
same position as there is a great advantage in changing from the crib to 
the nurse's arms. Careful attention should be given to feeding (page 
190) and to the condition of the bowels. A cathartic, preferably castor 
oil, should be administered at the outset. Distention of the stomach and 
bowels with gas adds greatly to the discomfort of the patient, and may 
cause serious symptoms. 

Abortive measures are rarely successful, for, by the time the physician 
is summoned, the disease is generally so well established that they are 
futile. Mild cases may sometimes be cut short by a hot foot-bath, free 
catharsis, and diaphoresis, especially by the use of phenacetine and Dover's 
powder (phenacetine three grains, Dover's powder one grain, to a child of 
three years). 

Local applications. — Poultices are objectionable on account of their 
weight and the difficulty in getting them properly applied. For in- 
fants the oiled-silk jacket (page 59) is decidedly preferable. This should 
be applied in the beginning, and may be worn throughout the attack. It 
accomplishes all that a poultice does, with much less disturbance to the 
patient. Counter-irritation is very valuable. In infante the besl results 
are obtained by the frequent use of a mustard paste (page 52). It should 
be large enough to envelop the chest, and covered by a towel, so as not t<> 
soil the oiled-silk jacket or the clothing. The paste is removed as Boon as 
the skin is thoroughly reddened, which will be in from five to ten min- 
utes, according to the strength of the mustard and the condition of the 
child's skin. The skin should then he dried and the oiled-silk jacket 
again pinned snugly about the chest. This may be repeated, aocordii 



468 DISEASES OP THE RESPIRATORY SYSTEM. 

indications, from two to eight times a day. If properly used, it may be 
continued for a week without causing any soreness of the skin. 

Inhalations. — The value of these is not sufficiently appreciated. They 
may in the great majority of cases take the place of the administration of 
drugs by the mouth, a very great advantage in infants. They may be 
used by means of the croup kettle or vapourizer (pages 58 and 59), the 
child always being placed in a tent. In the early part of the disease 
relaxing inhalations, like simple watery vapour or limewater, may be 
used. Later turpentine, creosote, terebene, or eucalyptol may be added. 
Of these, creosote has given me the most satisfaction. Inhalations are 
to be used for ten or fifteen minutes from four to twelve times a day. 

Expectorants. — In infancy this class of drugs may usually be advan- 
tageously dispensed with. For older children the relaxing expectorants, 
especially antimony and ipecac in combination, may be used in the first 
stage. When the secretion is more abundant, either the alkaline or the 
stimulating expectorants may be given. Of the former, the best are liquor 
potassae, citrate of potassium, and muriate of ammonia ; of the latter, creo- 
sote, turpentine, terebene, and squills. Small, frequently repeated doses 
usually give the best results. 

Opium. — This should be given very cautiously to young infants, as it 
is capable of doing great harm. The dry, harassing cough of the early 
stage sometimes yields to nothing so quickly as to small doses of Dover's 
powder (e. g., one tenth of a grain every two hours to a child of one year). 
In the case of infants, late in the disease, and especially in severe cases, 
opium should be withheld altogether. It disturbs the stomach, consti- 
pates the bowels, and, most of all, it greatly depresses the respiration. 

Emetics may sometimes be used with advantage when the secretion is 
very abundant and the cough feeble, but they should be avoided with weak 
pulse, great prostration, and slight stupor. Syrup of ipecac is the best 
emetic under these conditions. 

Cardiac stimulants. — These are required in most of the severe cases. 
The best is alcohol. It should be begun as soon as indicated by weak 
pulse and general prostration. For a child a year old, from half an 
ounce to one ounce of brandy, diluted with from six to eight parts of water, 
should be given in each twenty-four hours, in small doses at short intervals. 

Respiratory stimulants. — The most valuable drugs are strychnine and 
atropine. To an infant of six months -^^ grain of strychnine and -^-^ 
grain of atropine may be given every two hours. For a short time twice 
these doses may be used. They are needed only in the most severe cases, 
and may be used in combination or alternately. An important respira- 
tory stimulant is counter-irritation over the entire body by the mustard 
paste or hot mustard bath. 

The management of mild cases in infants. — In the great majority of 
cases the disease is self-limited, tending to spontaneous recovery. Often 



ACUTE CATARRHAL BRONCHITIS. 469 

no treatment is needed, except the hygienic measures mentioned. An 
oiled-silk jacket should be applied. If the cough is excessive, inhalations 
of creosote or turpentine three or four times a day may be used, or small 
doses of Dover's powder or phenacetine. The oppression which often 
comes on toward evening may be relieved by a mustard paste at bedtime. 
Stimulants are not required. All other drugs may be advantageously 
omitted, but during convalescence cod-liver oil should be given. 

The management of severe cases in infants. — These must be treated 
very much like cases of broncho-pneumonia. The temperature is rarely 
high enough to require interference, but the chief danger is due to the 
inability of the child to get rid of the secretion by the cough. In my 
experience the two most valuable means of treatment have been the use 
of inhalations and counter-irritation. The former should be repeated for 
ten or fifteen minutes every two hours, and for a short period may often 
be given with advantage every hour. Early in the disease, vapour of 
plain water or lime water may be used ; later, creosote is best. Counter- 
irritation by the mustard paste should be repeated every three hours, 
and the oiled-silk jacket worn continuously. Alcoholic stimulants are 
usually needed in delicate children, and in secondary bronchitis accom- 
panying the infectious diseases. In most of the cases the medication 
should consist only of cardiac and respiratory stimulants. In strong chil- 
dren the occasional use of an emetic at bedtime is admissible. 

Attacks of suffocation and respiratory failure. — The indications here 
are to get as much blood as possible to the surface and to the extremities, 
in order to relieve the overloaded right heart, and to compel the child to 
make full and deep inspiratory efforts. One plan of treatment (Jacobi's) 
is to induce frequent crying by flagellation or spanking, this being kept 
up for several hours. Another (II. C. Wood's) is to use alternately hot 
and cold douches to the chest until some reaction is obtained, and then to 
follow up this by the occasional use, for a few moments, of a very hot bath 
(120° F.). Both these means, but especially the first mentioned, are of 
great value, as I have had abundant opportunity to verify. Another use- 
ful measure is the hot mustard bath, or the hot mustard pack applied to 
the entire body. In conjunction with the above means, both hearl and 
respiratory stimulants should be given in full doses. If possible, oxygen 
should be administered. As these symptoms are liable to recur every few 
hours for a day or two, a repetition of the treatment will be Deeded, and 
if possible the physician should remain with the patient. 

If a young infant can be tided over these critical attacks, recover} is 
probable. After this danger is past, the treatment previously indicated 
may be pursued. The use of expectorants, particularly the composite 
cough mixtures containing opium, can not be too Btrongly condemned 
in all severe cases of infantile bronchitis. 

The management of cases in older children. — In the non-febrile cases 



470 DISEASES OF THE EESPIRATORY SYSTEM. 

confinement in bed is unnecessary, but children should be kept indoors. 
In the early stage, with hard, dry cough, one of the best remedies is brown 
mixture (the mistura glycyrrhizse composita of the IT. S. P.). It will 
be found advantageous in most cases to have the formula made up with 
one half the usual amount of opium. When the cough is especially hard 
and dry, a single inhalation may be used at bedtime. In the second stage, 
muriate of ammonia may be added to the mixture ; or terebene, two or 
three drops upon sugar, may be given four or five times a day ; and in- 
halations of creosote or turpentine should be used. 

In the more severe cases accompanied by fever the patients should be 
kept in bed and an oiled-silk jacket applied. In the beginning the liquor 
ammoniae acetatis and spiritus aetheris nitrosi may be given for their effect 
upon the skin and kidneys. For the general discomfort, pain, headache, 
etc., nothing is better than phenacetine and Dover's powder (three grains 
of the former to one grain of the latter to a child of five years), repeated 
every three to six hours. For the cough the same remedies may be used 
as in the mild cases. All patients should be kept in bed as long as the 
temperature is above normal. Subsequently, the cases may be managed 
as in the milder form of the disease. 

The protracted cough of convalescence. — It often happens, both in 
infants and in older children, that after all physical signs and constitu- 
tional symptoms have disappeared, a cough continues sometimes for weeks. 
Expectoration is scanty, or is wanting altogether ; the cough is hard, dry, 
often paroxysmal, and in some cases occurs at night only. For this con- 
dition the best remedies are quinine, cod-liver oil, and creosote. The last 
named may easily be given to young infants as well as to older children, in 
combination with liquid beef peptonoids.* It may be also used in pill form 
or by inhalation. These measures may be tried alternately or in combina- 
tion. Where they are not effective a change of climate should be advised. 

FIBRINOUS BRONCHITIS (BRONCHIAL CROUP). 

Fibrinous bronchitis is seen in diphtheria, usually as an extension from 
the larynx or trachea. There is, however, another form of bronchitis 
attended by a fibrinous exudate, which occurs as a primary disease. This 
is very rare in children. Weil has, however, collected twenty cases of the 
primary form. The etiology is obscure. It . is seen at all ages, from in- 
fancy up to puberty, and it may be either acute or chronic. From the cases 
thus far reported it would appear that the acute form is relatively more 
common in children than in adults. The disease may be confined to cer- 
tain branches of the bronchial tree, or it may affect all the bronchi, even 
to the minute subdivisions. The fibrinous membrane is found loose in 

* A preparation put up by the Arlington Chemical Company, and a very palatable 
way of giving creosote. 



CHRONIC BRONCHITIS. 471 

the tubes or adherent. There are generally associated other pulmonary 
changes, such as emphysema, areas of atelectasis or of broncho-pneumonia. 

The acute form somewhat resembles ordinary catarrhal bronchitis. 
The diagnostic features are the severity of the dyspnoea and the expectora- 
tion of tube casts from the larger bronchi, or elongated cylinders from 
the smaller ones, the former resembling macaroni, the latter vermicelli. 
The expectorated masses are often in balls or plugs, and their peculiar 
character is not recognised until they are placed in water. The casts 
are dissolved by alkalies, especially by limewater. After the expulsion of a 
large cast, improvement in all the symptoms occurs. These, however, 
return as the exudate reappears. The ordinary duration of acute cases 
is from one to three weeks. 

In the chronic form there are no constitutional symptoms, but only 
dyspnoea and cough, often recurring in paroxysms, with the expectoration 
of fibrinous casts. The patient may have these attacks at intervals of a 
few days or weeks, extending over a period of months, or even years. 
There are no characteristic physical signs. The diagnosis rests upon the 
peculiar character of the expectoration. The prognosis in acute cases is 
unfavourable, the mortality being 75 per cent (Weil). Chronic cases are 
not dangerous to life. 

Treatment. — This is quite unsatisfactory. To loosen the membrane and 
facilitate its expulsion, the most efficient means are inhalations of the 
vapour of limewater and the internal administration of pilocarpine. Oc- 
casionally emetics are of value. Improvement in some of the chronic 
cases has resulted from the use of iodide of potassium. 

CHRONIC BRONCHITIS. 

Chronic bronchitis is not a common disease in children, particularly 
in young children, one reason being that chronic emphysema, so fre- 
quently an associated condition in adults, is rare in early life. Chronic 
bronchitis always accompanies chronic pulmonary tuberculosis and chronic 
interstitial pneumonia, with or without the occurrence of bronchiectasis. 
It is seen in chronic cardiac disease, especially with lesions of the mitral 
valve. It may occur as a late symptom of hereditary syphilis. Excluding 
the varieties mentioned, it usually follows attacks of acute bronchitis, the 
process becoming chronic because of the patient's constitutional condition 
or his unhygienic surroundings. The acute attack may bo primary, but it 
often follows measles and whooping-cough. Rickets, general malnutrition, 
and lymphatism are the constitutional conditions in which acute bronchitis 
is most likely to pass into the chronic form. Deformities of the chest, 
the result either of rickets or of Pott's disease, arc occasionally a cause. 

Symptoms. — The only constant symptom is cough, which is persistent, 
obstinate, and nearly always worse al uighl or early in the morning. It 
often occurs in paroxysms strongly suggestive of pertussis. Expectora- 



472 DISEASES OF THE RESPIRATORY SYSTEM. 

tion is not generally abundant, but in older children there is usually some 
expectoration present, and in a few cases it is profuse. A copious morn- 
ing expectoration of fetid pus or muco-pus indicates bronchiectasis. 
There is no fever, little or no dyspnoea, and although the patients are thin 
they are not emaciated, and in many cases the general health is not much 
affected; There may be coarse mucous rales, or no physical signs what- 
ever. The duration of the disease is indefinite, depending upon the 
cause. All these patients are better in summer and worse in winter, 
and suffer frequently from exacerbations of acute or subacute bronchitis. 

The diagnosis is to be made mainly from pertussis and tuberculosis. 
From mild attacks of pertussis the diagnosis may be impossible except by 
the course of the disease. Tuberculosis may be suspected if the thermom- 
eter shows regularly a slight evening rise of temperature, if there is much 
anaemia, and steady loss of flesh. A positive diagnosis can be made only 
by the discovery of tubercle bacilli in the sputum. 

Treatment. — The first indication is to treat the primary disease. In 
cardiac cases digitalis is the best remedy, and all sedatives are to be 
avoided. Attention should be directed to the general condition — rickets, 
malnutrition, and lymphatism each receiving its appropriate treatment. 
In most cases a general tonic plan of treatment is best, particularly the 
continuous use of cod-liver oil. In many cases a change of climate is the 
only thing which is really curative. For the relief of cough, opiates are 
to be avoided as much as possible. The main reliance should be upon 
potassium iodide, creosote and terebene, given both by mouth and by 
inhalation. 

REFLEX COUGH— NERVOUS COUGH. 

Strictly speaking, all cough is reflex and of nervous origin. The term 
" reflex cough " is, however, commonly used to denote that which occurs 
without any evidence of disease in the larynx, trachea, bronchi, lungs, or 
pleura. On account of the close nervous connection through the vagus 
and its branches between the mouth, ear, throat, stomach, and thoracic 
organs, it is possible for cough to be produced by many forms of irritation 
in these organs or cavities. Clinically, the following varieties of nervous 
cough are observed : 

1. That dependent upon pharyngeal irritation. One cause of this is an 
elongated uvula. This cough occurs usually at night, and is tickling, hack- 
ing, or hemming in character. A similar irritation may be produced by the 
trickling of mucus into the lower pharynx from the nose or rhino-pharynx. 

2. That due to aural irritation. This is rare, and may be associated 
with chronic otitis of any variety. It has no special characteristics. 

3. That due to gastric irritation — the " stomach cough." This is 
much more frequent than the other forms. It is usually associated with 
chronic indigestion and occurs both in infants and in older children. 



REFLEX COUGH. 473 

4. That due to dental irritation. The cough of dentition is often 
spoken of, although I have never seen a case which could fairly be as- 
cribed to it. 

5. Cardiac cough. This is usually associated with mitral disease, 
and due to pulmonary congestion. The cough is dry, hard, and often 
severe. 

6. The variety which occurs usually about the time of puberty, and 
often associated with anaemia, chorea, or spinal irritation. It is a short, 
hacking, or teasing cough, sometimes very distressing, and it seems to be 
a manifestation of extreme nervous irritability. 

7. The periodical night cough, which is generally ascribed to irritation 
of the vagus or its branches by enlarged, sometimes caseous, lymph nodes 
of the tracheo-bronchial group. This often occurs in severe paroxysms, 
the character of which is very much like pertussis. The attacks are apt 
to come on about the middle of the night and last for several hours. 
Vomiting is rare. The cough may recur regularly every night for months. 
On account of the loss of sleep the patient's general health may be con- 
siderably undermined. 

8. A very similar cough may occur in connection with abscesses in the 
posterior mediastinum due to Pott's disease. 

Symptoms and Diagnosis. — These cases are not common in infants, 
but are quite frequent in older children. In nearly all the varieties 
the cough is worse at night, and in many it may be confined to that 
time. The influence of habit is often seen, the attacks coming on regu- 
larly at certain periods. The general health may not be affected, except 
from the disturbance of sleep. The diagnosis between the different 
forms is often very difficult. The precise cause in a given case is discov- 
ered only by a careful examination of the ear, nose, pharynx, heart, stom- 
ach, lungs, and a consideration of the patient's general condition. The 
existence of enlarged or tubercular bronchial glands may be suspected in 
patients of tubercular antecedents, in those who have previously suffered 
from measles, pertussis, or repeated attacks of bronchitis, and when the 
cough is very severe and paroxysmal. A similar group of symptoms may 
exist with abscesses from Pott's disease. In either of these conditions 
there may be attacks of suffocation. 

Treatment. — Opium and expectorants are not indicated, and inhala- 
tions are of little value. The only successful treatment is fchal which is 
directed to the cause of the disease. If qo cause can be found, and the 
cough appears to be of purely nervous origin, the best results follow the 
use of the bromides or the administration of antipyrine at bedtime. 

ASTHMA. 

Asthma may be defined as a vaso-motor neurosis of the respiratory 
tract. It is characterized by attacks of severe spasmodic dyspnu>a, which 



474 DISEASES OF THE RESPIRATORY SYSTEM. 

may be preceded, accompanied, or followed by bronchial catarrh of greater 
or less severity. In the asthmatic attacks of infancy the catarrhal ele- 
ment is very prominent, and these cases present quite a different clinical 
picture from the disease as seen in older children, which differs in no 
essential points from the asthma of adults. 

Writers differ very much in their statements regarding the frequency 
of asthma in early life, mainly because of a want of agreement in re- 
gard to what shall be included under this term. The asthmatic attacks 
of infants are considered by some as a stage of bronchitis, by others as 
distinct from that disease. Typical attacks resembling those of adult life 
are rare in children, and extremely so before the seventh year. How- 
ever, of 225 cases of asthma reported by Hyde Salter, the disease began 
before the tenth year in nearly one third the number. 

Etiology. — The general or constitutional causes are the same in chil- 
dren as in adults. Asthma may be hereditary. It occurs especially in 
children whose antecedents have suffered from gout or from other neu- 
roses. The local cause may be any form of irritation in the nose or « 
pharynx — hypertrophic rhinitis, adenoid growths of the pharynx, hyper- 
trophied tonsils, or elongated uvula — or in the bronchial mucous mem- 
brane, as a result of previous attacks of acute" bronchitis. It is probable 
that it may also be caused by the irritation of enlarged bronchial glands. 
In susceptible persons a paroxysm may be excited by cold or damp air, 
indigestion, constipation, or the inhalation of various irritating sub- 
stances, such as dust, the pollen of certain plants, etc. First attacks of 
asthma in children are apt to follow bronchitis. 

Symptoms. — Pour quite distinct clinical types of asthma are seen in 
children : (1.) Oases which in their onset simulate attacks of capillary 
bronchitis. (2.) Those in which asthmatic symptoms follow an attack of 
bronchitis, continuing for weeks or months, but not necessarily recur- 
ring. (3.) Hay fever, or the periodical form which occurs every summer. 
(4.) That which resembles the ordinary adult asthma, with the nervous 
element predominating. The prominence of the catarrhal symptoms is 
characteristic of all asthma of children, the first two varieties being 
peculiar to early life. 

Attacks resembling capillary bronchitis. — These cases are rare, but 
may be seen even in infants. The onset is sudden, with moderate fever, 
incessant cough, severe dyspnoea, and sometimes symptoms of suffocation 
— cyanosis, prostration, and cold extremities. The chest is filled with 
sonorous, sibilant, and soon with subcrepitant rales. Instead of running 
the usual course of bronchitis of the finer tubes, the symptoms may pass 
away very rapidly, and in forty-eight, sometimes in twenty-four, hours the 
patient may be quite well. It is only by the course of the disease and by 
recurring attacks that their true nature can be recognised. In infants 
this form may be fatal. 



ASTHMA. 475 

Cases following attacks of bronchitis — Catarrhal asthma. — This form is 
not uncommon, though it is frequently designated by some other term than 
asthma — sometimes as spasmodic bronchitis, or catarrhal spasm of the bron- 
chi. The symptoms are, however, indistinguishable from asthma, and 
they evidently belong in the same category. This form is usually seen in 
infants, being rare after the third year. Many of the patients are rachitic ; 
others have large tonsils, or adenoid growths of the pharynx ; while in 
still others there is every reason to suspect the presence of large bronchial 
glands. Usually there is nothing peculiar about the antecedent bronchitis ; 
in most cases it is not especially severe, and is limited to the larger tubes- 
The febrile symptoms subside in a few days, but the cough continues, 
as do also the dyspnoea and wheezing. When the symptoms are fairly 
established they are very uniform and characteristic. The respiration is 
accelerated, usually to 50 or 60, sometimes to 70 or 80, a minute. The 
temperature from time to time may be very slightly elevated, or it may 
remain normal. The respiration is noisy, laboured, and accompanied by 
distinct wheezing, which can sometimes be heard all over the room. 

On auscultation, there is prolonged expiration accompanied by loud, 
wheezing rales, either sonorous, sibilant, or musical, and occasionally 
moist rales are present. In cases which have lasted some time a moderate 
amount of emphysema can be inferred from prominence of the infraclavicu- 
lar regions, and exaggerated resonance over the chest in front. 

These symptoms and signs may continue for three or four weeks only, 
and gradually wear off, or they may last as many months — if they begin in 
the winter or spring, often continuing until the middle of the summer. 
While they are constantly present, they vary in intensity from time to time, 
being usually much worse at night. The symptoms are always increased 
by exposure to a cold, damp atmosphere, by any fresh accession of bron- 
chitis, and often by trivial digestive disturbances. The average duration 
of the cases I have seen was six or eight weeks. The cough is not usually 
severe, and expectoration in most cases is absent. The general health is 
often but little affected. With recovery from the asthmatic symptoms the 
emphysema usually disappears gradually, although 1 have seen one severe 
case in Avhich it persisted. 

What proportion of these children afterward develop ordinary asthma, 
from personal experience I am unable to say. Some undoubtedly do, hut 
in others which I have been able to follow, recovery has seemed to he 
permanent. This would appear more likely in those eases closely associ- 
ated with rickets, or with other causes which disappear spontaneously 
with time or as a result of treatment. 

Hay fever. — This is very rare before the seventh, and bul few well- 
marked cases are seen before the tenth year. In its clinical aspects it does 
not differ essentially from the disease as Been in adults, except possibly 
by the greater prominence of the bronchial catarrh. 



476 DISEASES OF THE RESPIRATORY SYSTEM. 

Ordinary attacks of the adult type. — These usually occur at inter- 
vals of a few weeks or months, depending upon the nature of the exciting 
cause. The beginning is usually at night, with dyspnoea, a short, dry 
cough, and loud, wheezing respiration. Deep recession of the soft parts 
of the chest is seen, as in laryngeal stenosis. There is prolonged ex- 
piration, accompanied by loud, sonorous, sibilant and wheezing rales, and 
the vesicular murmur is very feeble. Later, moist rales may be heard. 
After many attacks emphysema is present. This occurs more rapidly than 
in adults, and may be extreme, giving rise in marked cases to serious 
thoracic deformity. On account of the loss of sleep and interference with 
nutrition, the general health may become seriously impaired. 

Diagnosis. — Typical attacks of asthma are easily recognised. Some of 
the catarrhal forms seen in infancy, however, present great difficulty, and 
a positive diagnosis may be impossible except by the progress of the case. 

Prognosis. — This is best in the cases of catarrhal asthma in infants, 
and in older patients when it depends upon some local cause which can 
be removed, as when the disease is due to reflex nasal or pharyngeal irrita- 
tion. In the majority of other cases, asthma is likely to become chronic 
unless the child is removed to some climate in which the attacks do not 
occur. The younger the child, the shorter the duration of the disease, 
and the less marked the hereditary tendency, the better the prognosis. 

Treatment. — The nose and the rhino-pharynx should be carefully 
examined in every case of asthma, and any pathological condition there 
present should be removed as the first step in the treatment. Special 
importance, in children, should be attached to the removal of adenoid 
growths of the pharynx. During attacks, the best means' of relieving the 
symptoms is the inhalation of fumes of nitre paper or stramonium leaves. 
Most of the proprietary remedies (Papier de Fruneau, Himrod's cure, 
and Kidder's pastilles) contain these ingredients. The last two prepara- 
tions being, as is reported, a combination with sage, are particularly well 
tolerated. The sleeping room may be filled with the fumes from these 
substances, or the child may be placed in a tent into which the fumes 
are introduced. Emetics should be employed when the attack is brought 
on by indigestion. Lobelia is the most satisfactory remedy for this pur- 
pose. To prevent the recurrence of night attacks, nothing in my experi- 
ence has been so valuable as a full dose of antipyrine at bedtime — four 
grains at five years and six grains at ten years. Between the attacks the 
main reliance should be upon the syrup of hydriodic acid and potassium 
iodide, which are to be given for a long time in full doses. Tonics are 
to be used in nearly all cases. Those especially valuable in asthmatic 
patients are cinchonidia and arsenic. 

In the cases of catarrhal asthma following bronchitis, expectorants 
and ordinary cough remedies are useless. Cod-liver oil and the iodide 
of potassium are valuable in some of the cases. Others get much relief 



PNEUMONIA. 477 

from the regular use of creosote inhalations several times a day, with a 
nightly dose of antipyrine. The fumes of nitre and stramonium often 
afford no relief, and sometimes the cases are made distinctly worse by 
them. The best of all measures is to send the child at once to a warm, 
dry climate. 

For all children who have had repeated attacks, whether in the form 
of hay fever or the ordinary variety, the most important thing is removal 
to a place where they do not have the disease, and a residence there long 
enough to break up the tendency to recurrence. This will usually require 
at least three or four years. The region best suited to most asthmatics is 
one which is high, dry, and moderately warm. Patients often suffer less 
in cities than in the country. If taken early, asthma in children is fre- 
quently curable by these means ; if neglected, the disease is almost sure 
to continue until adult life. 



CHAPTER IV. 

DISEASES OF THE LUNGS.— {Continued.) 
PNEUMONIA. 

In early life the lungs are more frequently the seat of organic disease 
than any other organs in the body. Pneumonia is very common as a pri- 
mary disease, and ranks first as a complication of the various forms of 
acute infectious disease of children. It is one of the most important 
factors in the mortality of infancy and childhood (page 39). 

Cases of acute pneumonia are divided, from an anatomical point of 
view, into two principal groups : (1.) Broncho-pneumonia, also known as 
catarrhal and as lobular pneumonia. (2.) Lobar pneumonia, also known 
as croupous and as fibrinous pneumonia. These differ from each other 
as to the products of inflammation, the distribution of the disease in the 
lung, and somewhat as to the parts involved and the nature of the changes 
in them. 

In broncho-pneumonia the large bronchi are the seat of a superficial 
inflammation, while in those of small size the entire bronchial wall ia 
affected; the exudation into the air vesicles is mainly cellular, being 
made up of epithelial cells, leucocytes, and red blood-cells (Fig. 72), 
fibrin being either absent, or present only in small amount. In many 
cases there are marked changes both in the alveolar septa and in the in- 
terstitial tissue of the lung; resolution is often imperfect, and there is a 
strong tendency of the inflammation to pass into a chronic form, in- 
volving the connective-tissue framework of the lung. The Lesion is 
widely and often irregularly distributed, usually being mosl marked in 



478 DISEASES OF THE RESPIRATORY SYSTEM. 

the vicinity of the small bronchi, from which the inflammation spreads, 
and in the most superficial lobules of the lung. 

In lobar pneumonia, bronchitis, when present, is usually superficial, the 
walls of the bronchi being very slightly or not at all affected ; the same 
is true of the alveolar septa. The principal product of the inflammation 
is fibrin (Fig. 73), which fills the alveoli and the terminal bronchi, the cells 
being relatively few and chiefly leucocytes. The process is usually sharply 
circumscribed, involving an entire lobe or a part of a lobe. In most cases 
it clears up rapidly and completely, there being but little tendency to in- 
volve the framework of the lung in a chronic process. 

While in typical cases the two forms of inflammation are quite dis- 
tinct, there are seen many intermediate forms which partake of the char- 
acters of both, and one may be in doubt, even after a microscopical ex- 
amination, into which group to place a case. It not infrequently happens 




Fig. 72. — Broncho-pneumonia. The picture shows an air vesicle filled with large epithelial cells 
having small nuclei ; the cells are swollen, desquamating, and partly broken down. There 
are also leucocytes with intensely black nuclei and narrow protoplasm. Between the cells 
is a finely granular material, which is the exudation fluid coagulated during the hardening 
process. The alveolar septa are somewhat infiltrated. — From Karg and Schmorl. 

that both varieties of pneumonia are present in different parts of the same 
lung or in opposite lungs at the same time. These mixed forms are espe- 
cially frequent during the second and third years ; but during the first 
year, and after the third, the types are usually well marked. 



PNEUMONIA. 479 

The following table shows the relative frequency of lobar and broncho- 
pneumonia in three hundred and seventy cases,* nearly all taken from 




•* 






Fig. 73.— Lobar pneumonia. In the air vesicle shown in the picture there is a firm, close net- 
work of fibrin, in the meshes of which are leucocytes. At the lower part the exudation has 
contracted away from the wall in consequence of the process of hardening.— From Karg 
and Schmorl. 

one institution (New York Infant Asylum). There are included all the 
cases of acute primary pneumonia occurring during a period of seven 
years : 

Under six months, broncho-pneumonia, 73 cases; lobar pneumonia, 11 cases. 
Six to twelve " " 96 " " " 29 « 

Second year, " 73 " " " 40 " 

Third " " 19 " " " 28 " 

Fourth " " " " " _6 " 

Totals, " 261 " " " L09 M 

Thus it will be seen that, of the cases of acute pneumonia occurring 

during the first two years, 25 per cent were lobar and 75 percent were 

broncho-pneumonia. 

When we come to a consideration of the micro-organisms with which 

the different forms of pneumonia arc associated, we find thai they do uol 



* The division was here made according to the predominant clinical or pathological 
features. Most of the doubtful cases were classed as broncho-pneumonia. 



480 DISEASES OF THE RESPIRATORY SYSTEM. 

correspond to the anatomical varieties. Lobar pneumonia is regularly 
associated with the presence of the pneumococcus (micrococcus lanceo- 
latus), which in most cases is fouud pure. In broncho-pneumonia no 
one form is always present. In the primary cases the pneumococcus is 
usually found, and in many cases it is alone. In the secondary cases 
there is almost always mixed infection. In measles and diphtheria the 
streptococcus is the principal form, such cases being usually of the worst 
type. In other secondary cases there are found the staphylococcus, and 
sometimes Friedlander's bacillus. Each of these varieties of bacteria may 
be found alone, but they are often associated, and with any of them may 
be found the pneumococcus, or other specific germs, most frequently the 
bacillus of influenza, diphtheria, or tuberculosis. 

The reason why the same cause — the pneumococcus — in one case pro- 
duces broncho-pneumonia and in another lobar pneumonia, is in part 
owing to the difference in the structure of the lung at the different ages — 
that of infancy being more bronchial, and that of older children more 
vesicular (page 460). Another reason is to be found in the constitu- 
tion of the patient : in the very young and in feeble and delicate chil- 
dren, the process tends to become diffuse and the products are chiefly 
cellular ; in those who are older and more vigorous it is likely to be cir- 
cumscribed, with fibrin as its chief product ; in the intermediate ages 
and intermediate conditions the types are often mingled. 

Etiologically as well as clinically, lobar pneumonia is a single disease, 
usually running a regular self-limited course. Broncho-pneumonia, on 
the other hand, includes a number of quite distinct diseases, which are 
not only etiologically but clinically different. Sometimes when it is due 
to the pneumococcus it has more features in common with lobar pneu- 
monia than with cases of broncho- pneumonia due to another kind of 
infection, such as the streptococcus. 

The immediate source of infection of the lungs is the mouth, the nose, 
or the pharynx. All the forms of bacteria found in pneumonia are found 
in these cavities, some of them constantly, others only at certain times, 
especially during an attack of any of the acute infectious diseases. What 
part direct contagion plays in the spread of pneumonia can not be settled 
without fuller data than at present exist. There seems to be no doubt, 
from clinical observations alone, that the secondary forms, especially those 
complicating measles and diphtheria, are sometimes communicated in this 
way. This is probably not often true of primary cases, except in hospitals 
for infants where the rapid development of case after case in the same 
ward can not be well explained on any other hypothesis. 

The different forms of pneumonia which will be considered are : 1. 
Acute broncho-pneumonia. 2. Acute fibrinous pneumonia. 3. Acute 
pleuro-pneumonia. 4. Hypostatic pneumonia. 5. Chronic broncho- 
pneumonia. 



ACUTE BRONCHO-PNEUMONIA. 481 

Tubercular broncho-pneumonia will be discussed in the chapter de- 
voted to Tuberculosis. 



ACUTE BRONCHO-PNEUMONIA. 

Synonyms : Catarrhal pneumonia, lobular pneumonia, capillary bronchitis. 

This is essentially the pneumonia of infancy. Under two years, the 
great majority of the cases of primary pneumonia are of this variety, and 
throughout childhood nearly all the cases of secondary pneumonia. The 
term broncho-pneumonia describes a lesion rather than a disease, several 
quite distinct forms of infection being included under this head. Its mor- 
tality is high, because of the tender age of the patients in which the pri- 
mary cases occur, and also because when secondary it complicates the 
most severe forms of the acute infectious diseases of children. 

Etiology. — Age. The 426 cases of broncho-pneumonia of which I 
have notes occurred as follows : 

During the first year 224 cases, or 53 per cent. 

" second year 142 " " 33 " " 

" third " 40 " " 11 " " 

" fourth " 10 " " 2 " " 

" fifth " 4 " " 1 " 

426 100 

After four years broncho-pneumonia is very infrequent as a primary 
disease, although it is seen throughout childhood as a complication of the 
infectious diseases. 

Sex. In the primary cases males are more frequently affected than 
females, the proportion being five to four. In the secondary cases the 
sexes are about equally affected. 

Season. Of the cases referred to, 38 per cent occurred during the win- 
ter months, 31 per cent during the spring, 13 per cent during the Bum- 
mer, and 18 per cent during the autumn. While, therefore, nearly 70 per 
cent of the cases occurred in the cold months, broncho-pneumonia is seen 
throughout the year. 

Previous condition. Broncho-pneumonia affects all classes, hut is 
most frequent in children having poor hygienic surroundings, especially 
in inmates of institutions, and in those previously debilitated by constitu- 
tional or local disease. In 346 consecutive cases of primary pneumonia, 
110 were in good condition prior to the attack, and L26 were delicate, 
rachitic, or syphilitic. 

Previous disease. The following table gives a good idea of the condi- 
tions with which acute broncho-pneumonia is most frequently seen ; 443 
cases were classed as follow- : 

37 



482 DISEASES OF THE RESPIRATORY SYSTEM. 

Primary * 164 

Secondary to bronchitis of the large tubes 41 

Complicating measles 89 

" pertussis 66 

" diphtheria 47 

" acute ileo-colitis 19 

" scarlet fever 7 

" influenza 6 

" varicella 2 

" erysipelas 2 

443 

A large number of the patients had previously suffered from one or 
more attacks, of bronchitis, and fifteen previously had broncho-pneumonia. 

As an exciting cause, exposure to cold must still be classed among the 
potent factors of primary pneumonia. 

Bacteriology. — Much light has already been thrown upon broncho- 
pneumonia by bacteriology, but many points still remain to be settled. 
In 1889 Prudden and Northrup f showed that the broncho-pneumonia of 
diphtheria was usually due to the streptococcus. In 1891 Mosny J pub- 
lished a report upon 17 cases of broncho-pneumonia : 4 were primary, 7 
were secondary to measles, 3 to diphtheria, and 1 to scarlet fever. In the 
4 primary cases, the pneumococcus was found alone in 3, and the strepto- 
coccus alone in 1. In the 11 secondary cases, the pneumococcus was found 
in 3 ; in one of these, a case of measles, it was alone. The streptococcus 
was found in 10 cases — alone in 5, with the pneumococcus in 1, with the 
pneumococcus and Loeflfrer's bacillus in 1, with the staphylococcus in 2> 
with Friedlander's bacillus in 1 ; in one case Friedlander's bacillus was 
found alone, and in one case a peculiar streptococcus. 

In 1892 Netter # published a report upon 42 cases. He has not sepa- 
rated the primary and secondary cases. Of 25 cases in which but one 
form of bacteria was found, the pneumococcus was present in 10, the 
streptococcus in 8, the staphylococcus in 5, and Friedlander's bacillus in 
2. In the 17 cases of mixed infection, the streptococcus was present in 
15, the pneumococcus in 9, the staphylococcus in 8, and Friedlander's 
bacillus in 4. 

I am indebted to Dr. Martha Wollstein, Pathologist to the Babies' 
Hospital, for permission to include here the results of observations made 
by her but not yet published. I had the opportunity of observing most 
of the cases clinically, they having been treated in my wards. Thus 



* It is probable that a number of cases complicating influenza were included 
among these primary cases. 

f American Journal of the Medical Sciences, June, 1889. 
% Etude sar la Broncho-Pneumonie. Paris, 1891. 

# Archives de Medecine experimentale, January, 1892. 



ACUTE BRONCHO-PNEUMONIA. 4S3 

far 33 cases have been studied, 19 of which were primary and 14 sec- 
ondary. Of the secondary cases, 2 complicated measles, 3 diphtheria, 3 
marasmus, and 6 tuberculosis. The pneumococcus was found in 17 of 
the 19 primary cases, occurring alone in 9, with the streptococcus in 7, 
and with the staphylococcus in 1. Of the two remaining primary cases, 
the streptococcus was found alone in one, and with the staphylococcus in 
the other. Of the 14 secondary cases, the pneumococcus was present in 
11, and alone in 2, both of these being cases of measles. The pneumo- 
coccus was associated with the streptococcus in 1 (a case of diphtheria), 
with the staphylococcus in 2 (both marasmus cases), with the tubercle 
bacillus in 2, with the tubercle bacillus and streptococcus in 3, with the 
tubercle bacillus and the staphylococcus in 1. Of the three cases in 
which the pneumococcus was absent, all showed the streptococcus — once 
alone, once with the staphylococcus, and once with the tubercle bacillus. 

Our present knowledge of the bacteriology of broncho-pneumonia may 
be summarized as follows : In the primary cases the pneumococcus is 
nearly always present, and in a large proportion of the cases it occurs alone. 
In cases of mixed infection it is most frequently associated with the strep- 
tococcus. The secondary cases are usually due to a mixed infection. The 
pneumococcus is found in a large number of these cases, but plays a much 
less important part than the streptococcus, particularly in cases compli- 
cating measles, diphtheria, and scarlet fever. The staphylococcus is next 
in point of frequency in the mixed cases, and it may occur alone. Still 
less important is the part taken by Friedliinder's bacillus both in primary 
and secondary cases. The association of the pneumococcus in all of the 
six tubercular cases studied by Dr. Wollstein is of special interest, as it 
explains what is so often observed clinically, that in cases of tubercular 
broncho-pneumonia the symptoms are indistinguishable from the simple 
form. Three of these cases ran the course of simple acute broncho-pneu- 
monia, and were so diagnosticated during life. 

We have not yet sufficient data definitely to connect the different forms 
of infection either with any set of lesions or with any group of clinical 
symptoms. The cases due to streptococcus infection are usually the worst 
forms, and are apt to show widely disseminated lesions. The cases in 
which the onset and clinical history resemble lobar pneumonia, and where 
there are found extensive areas of consolidation, and often excessive pleu- 
risy, are usually due to the pneumococcus. 

Lesions. — The term broncho-pneumonia is now generally adopted as a 
generic one, and it is to be preferred either to lobular or catarrhal pneu- 
monia, as it gives prominence to the bronchial elemenl in the inflam- 
mation. The process may begin in the Larger tubes and gradually extend 
to those of smaller calibre, finally involving the pulmonary lobules in 
which these tubes terminate; or it may extend to the air vesicles which 
surround the tube in its course through the lung, so that in whatever 



484 



DISEASES OF THE RESPIRATORY SYSTEM. 



direction the lung is cut, there are seen surrounding the small bronchi, zones 
of pneumonia (Fig. 74). In other cases the process seems to begin almost 
at the same time in the small bronchi and the air vesicles, as both are found 
involved, even when death occurs within a few hours of the first symptoms. 
There are, however, cases in which the parts of the lung affected bear 
no relation to the bronchi — where there are found simply smaller or larger 




Fig. 74. — Broncho-pneumonia, with thickening of a small bronchus. In the centre of the pic- 
ture is seen a small bronchus, B, which is cut somewhat obliquely, so that the degree to which 
its wall, C, is thickened is well shown. It is partially tilled with pus, its mucous membrane 
is nearly destroyed, and its walls greatly thickened from infiltration with leucocytes. This 
infiltration extends to the lung tissue in the neighbourhood ; it forms a peri-bronchitic zone 
of pneumonia. Elsewhere in the picture the lung tissue, A, is practically normal. D is a 
small blood-vessel. E is another smaller bronchus. Throughout the lung everywhere accom- 
panying the small bronchi similar changes were seen, in addition to which there were present 
some large areas of consolidation. The disease was of four and a half weeks' duration ; the 
child, five months old. 



areas of pneumonia irregularly scattered through the lung, usually near 
the surface (Plate XII). From the distribution of the lesions such cases 
might better be termed lobular than broncho-pneumonia. 

Much has been said in the past about pulmonary collapse from ob- 



PLATE XII. 




Acute Broncho-Pneumonia. 

Primary pneumonia, in a child two years old, showing the irregular distribution <>f 
the hepatization and its incomplete character. A is the pleura somewhat thickened; 
Ii, lung tissue which is practically normal ; C C arc hepatized areas, scattered through 
which are groups of air vesicles still containing air. (Slightly magnified.) 



ACUTE BRONCHO-PNEUMONIA. 485 

struction of the small bronchi, as an antecedent condition to this form of 
pulmonary inflammation. So far as my own observations go, there has 
been adduced but little evidence that this is the rule, or, indeed, that it often 
occurs. Even in autopsies made very early in the disease, but little collapse 
was found, most of the cases supporting the view of Delafield, that when 
the disease extends from the bronchi to the air cells it involves those sur- 
rounding the tube quite as regularly as those to which the tube leads. 

The following observations are made from a study of 170 autopsies of 
which I have records, microscopical examinations having been made in 
about one third of the number. 

Seat of the disease. — In 82 per cent of the autopsies extensive disease 
was found in both lungs. The parts most affected were the lower lobes 
posteriorly; next to this the posterior part of both the upper and lower 
lobes. The left lower lobe was more extensively diseased than the right 
in over two thirds of the cases. Only a single lobe was involved in but 9 
per cent of the cases. It is not common for the disease to be situated in 
the anterior portion of the lung only, but when this occurs the right 
apex is the most frequent seat. 

Just as the clinical symptoms of broncho-pneumonia follow no regular 
type, so the pathological process does not pass through a regular order of 
changes such as are seen in lobar pneumonia. There are a certain number 
of cases which appear to follow tolerably well-defined stages of conges- 
tion, red hepatization, gray hepatization, and resolution ; but the dis- 
ease may be arrested at any of the stages and the case recover, or death 
may occur at any stage and there may be found at autopsy different por- 
tions of the lung representing all the stages mentioned. In considering, 
therefore, the lesions of broncho-pneumonia, it seems best to describe the 
condition in which the lungs are found at the various periods when death 
is likely to occur, rather than to attempt to describe the different stages of 
the disease, as in lobar pneumonia. 

1. The'acute congestive form (acute red pneumonia). — This is the con- 
dition in which the lung is usually found if death occurs during the first 
two or three days of the disease. In the cases severe enough to cause 
death in the first twenty-four hours, very little can be seen by the naked 
eye except acute congestion. The vessels of the pleura are distended, 
and there may be small superficial haemorrhages. Both lower lobes are 
usually heavy and dark-coloured. There is to the naked eve no consolida- 
tion. All, or nearly all, the lung can be inflated. On section, there is 
found intense congestion with some oedema When the process has lasted a 
little longer the affected areas are more sharply defined. These, usually the 
posterior portions of both lungs, are of a brownish-red colour, and appear 
partially hepatized, although with a little force they may in most east 
inflated. After section, pus and mucus flow from the divided bronchi, 
and the whole lung may be more or less congested or (edematous. 



486 



DISEASES OF THE RESPIRATORY SYSTEM. 



The microscope alone reveals the fact that these are not cases of sim- 
ple pulmonary congestion or bronchitis of the finer tubes. In one case in 
which death occurred twelve hours from the first symptoms, I found well- 



/*** 








Fig. 75. — Acute broncho-pneumonia with intra-alveolar haemorrhage (highly magnified). In the 
picture is shown a small vein, which, as well as the surrounding alveoli, is filled with blood- 
cells. In other respects the lung shown is normal. This is from the border of a consoli- 
dated area. Child fifteen months old : pneumonia of ten days' duration, with a severe ex- 
acerbation forty-eight hours before death, temperature 106° F. Extensive hemorrhagic areas 
were scattered through the lung most affected. 

marked evidences of inflammation of the air vesicles. In these hyper-acute 
cases, the microscope shows great distention of all the small blood-vessels 
of the affected area, and small or large extravasations of blood just be- 
neath the pleura, into the alveoli (Fig. 75) and interstitial tissue of the 
lung. In some cases these hemorrhages form the most striking feature 
of the lesion. The air vesicles are partially, some almost completely, filled 
with red blood-cells, swollen and desquamated epithelial cells, and a few 
leucocytes (Fig. 72). The red blood-cells predominate. The inflamma- 
tion may be diffuse, involving nearly a whole lobe, or in small areas in the 



ACUTE BROXCHO-PNEUMOXIA. 



487 



neighbourhood of the small bronchi (Fig. 76). The mucous membrane of 
the large and small bronchi is the seat of catarrhal inflammation, and the 
walls of the latter are infiltrated with round cells. 

When the process has lasted from twenty-four to forty-eight hours 
all the changes described are more marked, but the red colour of the in- 
flammatory products still persists. Such cases give during life only the 
signs of congestion and bronchitis. 

2. The mottled red and gray pneumonia. — This is the usual appearance 
when the disease has lasted somewhat longer, and is found in most of the 
cases dying between the fourth and fourteenth days. There are usually at 
this time quite large areas of consolidation, sometimes affecting nearly an 
entire lobe, so that at first sight the case may resemble lobar pneumonia. 
This is sometimes described as the " pseudo-lobar " form. The extent of 




Fio. 76.— Early stage of broncho-pneumonia. There is shown at P> B B small bronchi, some 
of which at the right of the picture have been cut somewhat obliquely, and hence appear 
irregular in shape. These bronchi everywhere contain pus; the air cells in the neigh 
bourhood are partially filled with leucocytes. The intervening pulmonarj tissue is normal. 
Child live months old. 



these areas depends largely upon the duration of the disease. In mosl cases 
there is pleurisy over the consolidated portions. This may cause the lung 
to adhere to the chest wall, the firmness of the adhesions depending upon 
the duration of the process. The surface 



of the lung is usually of a mot- 



488 



DISEASES OP THE RESPIRATORY SYSTEM. 



tied red and gray colour ; it often has a granular feel, due to the consoli- 
dation of some of the superficial lobules of the lung. On section, it is 
rarely found that an entire lobe is consolidated, the superficial portion 




-A 



Fig. 77. — Acute broncho-pneumonia. In the centre is shown a small bronchus, B, with a 
zone of pneumonia about it. The greater part of the section is made up of emphysematous 
lung tissue, E E, showing dilatation of the alveolar spaces and rupture of some of the 
alveolar septa. At the border, AAA, are seen the margins of consolidated areas of lung. 



being most affected, while the central part is normal or only congested. 
The colour is mottled, like that of the surface. In some places the hepa- 
tization appears complete ; in others the hepatized areas are separated by 
healthy, congested, or emphysematous lung tissue (Fig. 77). The gray 
areas surround the small bronchi and vary in size from a pin's head up- 
ward. The smallest ones look very much like miliary tubercles. The 
larger ones are seen where the process has existed for a longer time and 
has gradually invaded the contiguous air cells. If the lung is cut parallel 
with the bronchi, there may be seen small gray striae of pneumonia along 
their course (Fig. 74, C). From the cut bronchi, pus flows quite freely on 
pressure. The bronchial walls can often be seen even by the naked eye 
to be thickened. The parts affected are usually the posterior portions of 
the lower lobes of one side, the remainder of the lobes being congested or 
(edematous, while in front the lung is emphysematous. 

Under the microscope the smaller bronchi (Figs. 74 and 78) are seen 



ACUTE BRONCHO-PNEUMONIA. 



4S9 



to be much thickened and infiltrated with leucocytes. The gray areas 
surrounding the bronchi are made up of groups of air vesicles, which are 
packed with leucocytes (Figs. 79 and 80). Fibrin is sometimes seen in 
small amount, also red blood-cells and desquamated epithelial cells, but 
the leucocytes predominate. Surrounding the areas densely infiltrated 
are groups of air vesicles which are normal or congested, or which show 
only the earlier stages of the inflammatory process. Under the micro- 



X 



fr 



» ' • • 






-•v.<£j 



"«*> 



* <&M 







i 













Fig. 78. — Thickening of a small bronchus in subacute broncho-pneumonia following pertussis; 
child ten months old. The epithelium is well preserved, but the walls of the bronchus are 
infiltrated with leucocytes and show Borne enlarged blood-vessels. Magnified about thirty 
diameters. All the small bronchi in the lung examined showed similar changes. In addi- 
tion, there were superficial aria-- of consolidation in both Lungs behind. 

scope, even better than to the naked eye, is shown the irregularity of the 
consolidation. 

3. Gray pneumonia (persistent broncho-pneumonia). — This form is 
seen in protracted cases where there have been continuous Bymptoma 
usually for from four to eight weeks; it is not very uncommon. The 
pleuritic adhesions are more general and firmer. The amount of lung 



490 



DISEASES OF THE RESPIRATORY SYSTEM. 



involved may be very great, often nearly the whole of both lungs poste- 
riorly. The affected lung appears completely consolidated and slightly 
enlarged. On section, it is of a nearly uniform gray colour, sometimes of 
a yellowish gray. On pressure, pus exudes from the smaller and larger 
bronchi. The bronchial walls are markedly thickened, and in some places 
there may be a slight dilatation of the smaller bronchi. The part of the 
lung not consolidated may be almost white, owing to vesicular emphy- 
sema. In some cases there is also interstitial emphysema. Small cavi- 
ties containing pus may be found in the lung. The bronchial glands 







Fig. 79. — Broncho-pneumonia. Dense infiltration of pus cells in and about a small bronchus ; 
under a low power. The cavity shown in the specimen is a cross-section of one of the small 
bronchi, which is partially filled with pus cells; the epithelium is destroyed. The bron- 
chial wall and the pulmonary tissue in the neighbourhood are so densely infiltrated with 
leucocytes that almost every trace of normal structure is effaced. Child fifteen months old, 
disease of four weeks' duration. Extensive areas like this were found in both lunffs. 



are frequently swollen to the size of a large bean, and are of a reddish- 
gray colour. 

The microscope shows that the air vesicles of the consolidated portions 



ACUTE BROXCHO-PXEOIOXIA. 



491 



are distended chiefly with leucocytes, but there are also epithelial and con- 
nective-tissue cells. The alveolar septa may be so much thickened as to 




Fig. 80. — Acute broncho-pneumonia, under a low power, showing a portion of the lung, A. 
densely infiltrated with leucocytes. At B is a small bronchus, the wall of one side partly 
broken down by the inflammatory process. At the margin of the specimen J) are seen 
alveoli more or less filled with epithelial cells and leucocytes. At C is a small blood- 
vessel. In other parts of the lung small gangrenous areas were seen. The disease was 
of nine days 1 duration, the child seven months old. 

encroach upon the alveolar spaces (Fig. 81). Complete resolution is then 
impossible. 

Terminations. — Death may occur at any stage, or the pathological 
process may be arrested at any stage and the case go on to recovery. 
Resolution may take place before any consolidation recognizable by phys- 
ical signs has occurred; in such cases it is usually rapid and complete. 
If there has been consolidation, resolution may take place after two or 
three weeks and be complete, or it may be delayed for five or six weeks 
and still be complete. In many cases, especially those in which it is de- 
layed, resolution is only partial, and there are relapses or recurring attacks. 
After the first, or after several attacks, there may develop a chronic inter- 
stitial pneumonia; or simple pneumonia may be followed by tuberculosis. 
Such cases as these are to be carefully distinguished from the much more 
frequent ones in which the broncho-pneumonia has been tubercular from 
the outset. 



492 



DISEASES OF THE RESPIRATORY SYSTEM. 



Associated Lesions of the Lung. — Pleurisy is almost invariably found 
over every large area of consolidation, and in all cases of more than 
four days' duration ; while in most of those fatal within the first two or 
three days the pleura is normal or only congested. It is seen in all grades 
of severity, from a slight gray film of fibrin that can hardly be stripped 
off, to a yellowish-green exudation one fourth of an inch thick. A small 
amount of serum — one or two ounces — in the pleural sac is not uncom- 
mon, but a large serous effusion is very rare. Cases in which there is an 




Fig. 81. — Persistent broncho-pneumonia; highly magnified. There are shown at A A marked 
thickening of the alveolar septa, encroaching upon the alveolar spaces. All the alveoli, B B, 
are densely packed with leucocytes. A similar condition also through nearly the whole of 
the affected lung. (For history and temperature, see Fig. 90.) 

excessive inflammation of the pleura are considered elsewhere under the 
head of Pleuro-Pneumonia. Empyema occurs both during the stage of 
acute inflammation of the lung and while this is subsiding, but it is less 
frequent than in lobar pneumonia. 

Bronchial glands. — In all the recent acute cases these are swollen and 
red ; the usual size is that of a pea or a bean. They show microscopically 



ACUTE BRONCHOPNEUMONIA. 493 

the usual changes of acute hyperplasia. In protracted cases, and after 
repeated attacks, they may be two or three times the size mentioned, and 
of a gray colour. It is rare that they are large enough to give rise to 
symptoms unless they become the seat of tubercular deposits. 

Emphysema. — In almost all cases a certain amount of emphysema is 
present, it being more marked in the protracted cases. It is usually vesic- 
ular, involving the greater part of the upper lobes in front and the ante- 
rior margin of the lower lobes. Occasionally interstitial emphysema is 
seen, forming either large striae upon the surface of the lung, or blebs of 
considerable size along the anterior margin. This may occur even in 
cases uncomplicated by pertussis or laryngeal stenosis. 

Gangrene. — Gangrenous areas were found in six of my cases. In four 
of these the pneumonia was primary, in one it followed diphtheria, and in 
one ileo-colitis. It occurred in scattered areas of a grayish-green colour, 
varying from one fourth of an inch to two inches in diameter. 

Abscesses of the lung are by no means uncommon. They were noted 
in seven per cent of my autopsies. They are usually minute and multiple, 
varying in size from one sixth to one half inch in diameter. Sometimes 
a portion of a lobe is fairly honeycombed with minute abscesses. In one 
case a large abscess was found occupying the greater part of a lobe, the 
symptoms resembling those of empyema. Abscesses are usually found in 
regions where the inflammatory process has been especially intense. They 
may be found in prolonged cases, in those of unusual severity, as shown 
by excessively high temperature and rapid extension of the disease, and 
in very delicate subjects. The microscope shows that these abscesses usu- 
ally begin as an accumulation of pus in the small bronchi, whose walls 
become softened and break down on account of the intensity of the in- 
flammation (Figs. 79 and 80). They may be superficial, but are more 
commonly in the interior of the lung; they contain yellow pus and some- 
times broken-down lung tissue. Such abscesses can not be recognised 
clinically, and they are associated with other conditions which render the 
case almost certainly fatal. 

The lesions in other organs will be considered under Complications. 

Symptoms. — The clinical picture presented by broncho-pneumonia is 
an exceedingly varied one. There is no typical course. The cases differ 
from each other very markedly, but they may be divided into a few quite 
distinct groups. 

1. The acute congestive type. — This may be seen at any age, bui is 
more frequent in young infants. It may be either primary or secondary, 
being not uncommon in either form. Its symptoms are few and irregular, 
and the disease is often unrecognised. The entire duration may be only 
twenty-four hours. High temperature, extreme prostration, cyanosis, and 
rapid respiration may be the only symptoms. The temperature varies be- 
tween 104° and 107° F., usually rising steadily until death occurs. The 



494 DISEASES OF THE RESPIRATORY SYSTEM. 

prostration is extreme from the outset, the patient being overwhelmed by 
the suddenness and severity of the attack. Cyanosis is frequently present, 
and is almost always seen shortly before death. The respirations are from 
60 to 80 a minute, but in most cases not strikingly laboured. Cough is 
frequently absent. Cerebral symptoms are often marked. There are dull- 
ness and apathy, sometimes quite profound stupor, and not infrequently 
convulsions just before death. The physical signs are few and inconclu- 
sive. There is often nothing abnormal except very rude breathing over 
both lungs behind ; sometimes the breathing on one side is feeble, and on 
the other much exaggerated. There may be no rales whatever, and no 
change in the percussion note. 

The suddenness and severity of these symptoms are something which 
it is hard for one who has not observed them to appreciate. I have known 
an infant to die in twelve hours from the time in which it was apparently 
in perfect health, and had an opportunity to confirm the diagnosis of 
pneumonia by a microscopical examination of the lung. The diagnosis 
can not be positively made during life, and in most of the cases the dis- 
ease passes under some other name. It is often regarded as malignant 
scarlet fever or measles with suppressed eruption, or cerebro-spinal men- 
ingitis. 

If the children are sufficiently strong to withstand the first onset of 
violent symptoms, they may recover completely in four or five days, the 
lung clearing up very rapidly. In other cases these grave symptoms may 
abate in a day or two, to be followed by those of ordinary broncho-pneu- 
monia, which runs its usual course. 

The severity of the symptoms in these cases is to be explained partly 
on mechanical grounds. The air vesicles of the infant's lung are so small 
that the function of the lung is interfered with by very intense engorge- 
ment almost as much as by consolidation. This causes the sudden and 
intense embarrassment of respiration which it is difficult for the system 
to tolerate. The other symptoms are undoubtedly due to infection, being 
produced by the rapid absorption of toxines from the lungs. 

2. Acute disseminated broncho-pneumonia, or capillary bronchitis. — 
Although the symptoms in this class of cases are chiefly due to the bron- 
chitis, I have never failed to find at autopsy evidences of pneumonia also. 
These are not very common cases. The process begins as an inflamma- 
tion of the medium-sized and small bronchi, but not of the finest bronchi. 
The onset is acute, with fever, very rapid and laboured breathing, severe 
cough, moderate prostration, and in most cases cyanosis. 

The temperature is not high, usually only from 100° to 102° F., and it 
often continues so for three or four days. The pulse is rapid, and at first 
is full and strong. The respirations are exceedingly rapid, often from 80 
to 100 a minute. There is dyspnoea with marked recession of all the soft 
parts of the chest during inspiration. Cough is always present, usually 



ACUTE BRONCHO-PNEUMONIA. 495 

severe, and sometimes almost incessant. The prostration is not so great 
as in the cases previously described, and the development of the symptoms 
is much less rapid. 

There are at first sibilant and afterward subcrepitant rales over the 
entire chest, with which are usually mingled coarser moist rales. There 
are no evidences of consolidation. The respiratory murmur is everywhere 
feeble, but not otherwise altered. Percussion generally gives exaggerated 
resonance, owing to the emphysema which is present, the note being some- 
times almost tympanitic. 

The symptoms may gradually increase in severity until death takes 
place by the third or fourth day, from respiratory and cardiac failure. 
There is usually marked cyanosis, and toward the end rapidly increasing 
prostration. Just before death the temperature often rises rapidly to 106° 
or 107° F. At the autopsy there are found evidences of bronchitis of the 
tubes of all sizes, and minute zones of pneumonia about the smaller 
bronchi. The lungs are generally in a state of hyper-inflation, on account 
of which they do not collapse on opening the chest. There may be in 
addition extensive congestion or oedema, the development of which has 
been the immediate cause of death. 

In cases which do not prove fatal there is usually by the third or fourth 
day great improvement in the general symptoms ; the finer rales may dis- 
appear, and the coarse ones become more and more prominent. By the 
end of a week there may be complete recovery. Instead of this, there 
may be a continuance of the constitutional symptoms, and disappearance 
of the fine rales in front only, while behind there are gradually added to 
them the signs of consolidation in one of the lower lobes near the spine. 
From this time the case may progress as one of ordinary broncho-pneu- 
monia. 

The prognosis in this class of cases is very much better than in the 
congestive variety, recovery being probable unless the patients are very 
young or very delicate infants. 

3. Broncho-pneumonia of the common type. — When primary, this usu- 
ally begins suddenly with symptoms not unlike those of lobar pneumonia. 
This was the mode of onset in two thirds of my cases. In only ten per 
cent was the pneumonia preceded by bronchitis of the large tubes. In 
these the symptoms of bronchitis may be slowly (Fig. 91, p. 504) or rap- 
idly (Fig. 82) merged into those of pneumonia. When fche onset is sud- 
den it is marked by high fever, frequently by vomiting, rarely l>y convul- 
sions. In addition there are rapid respiration, cough, prostration, and 
sometimes cyanosis. The symptoms are more distinctly pulmonary than 
is generally the case in lobar pneumonia. 

The temperature, as a rule, is high; rarely is it continuously so, bul 
it is of a remittent type. The daily fluctuations often amount to four or 
five degrees. The fever usually continues from one to three weeks, and 



496 DISEASES OF THE RESPIRATORY SYSTEM. 

gradually subsides. It is rare for it to terminate by crisis. Although, 
as a rule, we expect a high temperature with acute pneumonia, this 
is not invariable. Primary cases may run their course, and even ter- 
minate fatally, although the temperature has not been above 101° F. 
I have records of several such cases. A low temperature is more often 
seen in young and delicate infants than in those who are older and more 
robust. 

The respirations are frequent and laboured ; there is real dyspnoea. 
On inspiration, there are marked recessions of all the soft parts of the 
chest, and the alse nasi dilate actively. The usual rapidity of the respira- 
tions is from 60 to 80 per minute ; very often, however, it rises to 100, and 
on several occasions I have seen it even 120. Eespiration generally seems 
more embarrassed than the action of the heart, and respiratory failure is 
a more frequent cause of death than cardiac failure. The pulse is always 
rapid — from 150 to 200 a minute — and when so it is often irregular. The 
pulse rate is of much less importance than its character. Early it is full 
and strong, but soon it becomes soft, compressible, and weak. 

The prostration is usually moderate for the first day or two, but 
steadily increases as the lung becomes more and more involved. Toward 
the close of the disease there may be present all the symptoms of the 
typhoid condition. 

Cough is much more constant than in lobar pneumonia, and more dis- 
tressing ; sometimes it is almost incessant. It disturbs rest and sleep, and 
may cause vomiting if the paroxysm occurs soon after eating. There is 
no expectoration. Mucus is sometimes coughed up into the trachea, or 
even the pharynx, to be swallowed again, or more frequently aspirated 
into the lung. If during a severe paroxysm the patient is turned upon 
his face or inverted, much of this mucus may be dislodged. A strong 
cough is a good symptom ; suppression of the cough is always a bad 
symptom, indicating a loss of the reflex sensibility of the bronchial mucous 
membrane and feeble respiratory muscles. 

Pain in the chest is not common, and is rarely an annoying symptom. 

Cyanosis is present at some time in most of the severe cases. It may 
occur at the onset, or at any time during the course of the disease. It is 
usually due to sudden congestion of a portion of the lung not previously 
involved. Even when slight, it is always a danger-signal of respiratory 
failure, and when present only in the finger tips or lips indicates that the 
patient must be carefully watched and energetically treated. In the severe 
cases the whole body may be of a dull leaden hue. 

Nervous symptoms at the onset are not so frequent as in lobar pneu- 
monia, convulsions being rare ; but late convulsions, particularly in the 
pneumonia which complicates pertussis, are exceedingly frequent, and 
usually fatal. Delirium may be present at any time during the attack. 
In infants this shows itself by excitement and inability to recognise the 



ACUTE BRONCHO-PNEUMONIA. 



497 



nurse or mother. Occasionally patients present marked cerebral symptoms 
throughout the disease. In one of my cases nearly every symptom of 
tubercular meningitis was present, the autopsy revealing only an extreme 
degree of cerebral anaemia. As elsewhere stated, the nervous symptoms 
depend not upon the location of the disease, but upon its extent, the 
intensity of the infection, and upon the susceptibility of the patient, such 
symptoms being especially common in rachitic children and in those suf- 
fering from pertussis. 

Gastro-enteric symptoms are frequent in infancy, and are of much 
importance. Often there are from four to six stools a day, of a green 
colour, containing mucus and undigested food. These symptoms depend 
upon the feeble digestion which is associated with the febrile process, 
and are often from improper feeding. This may lead to vomiting, which 
is also due to over-medication or to severe paroxysms of coughing. Vom- 
iting and diarrhoea add much to the danger of the attack, and not in- 
frequently, when the issue is doubtful, turn the scale against the patient. 
In summer this complication is more frequent and is likely to be more 
severe. Distention of the stomach or intestines from gas may be the 
cause of severe symptoms, owing to the added embarrassment of respira- 
tion produced by this upward pressure. In infants it may lead to attacks 
of cyanosis, and even convulsions. 

The urine in most cases is scanty, high-coloured, and loaded with 
urates. A trace of albumin is often present when the temperature is 
very high ; but casts, renal epithelium, and a large amount of albumin 
are rare. 

The following temperature chart (Fig. 82) is a good example of a very 
frequent course of primary pneumonia of moderate severity terminating 



105° II 1 


2 


:>, 


1 


5 t 


7 


8 


9 


10 


11 J12 |1S 11 15 10 




101° 

103° 
10^ c 
101° 
100° 
09° 








A 
























h 


A 


/ 




















r 


_^ 


J 


iN 


/ 


\ 


A, 
















\ 








V 




V 


\ 
















V 


J 












V 


^w 


M 




^ 


f 


V 




















w 



Fig. 82.— Temperature curve in typical broncho-pneumonia of the milder form. 

ffi8iory.—iB.&\e, sixteen months old; delicate child; previous bronchitis; onsel gradual; 
signs of consolidation at left base on fifth day,bu1 fine rales over both lower Lobes behind; peso 
lution slow, rales persisting for a long time in both lungs. 



in recovery. In cases of this type the constitutional symptoms are noi 
grave, and follow very closely the temperature curve. 

The next chart (Fig. 83) illustrates a more severe bui no1 uncommon 
course of the disease in which the fever is prolonged. The usual duration 
of cases of this type is between three and four weeks. The irregular fluc- 
tuations of the temperature, rarely touching the normal line, are exceed- 
ingly characteristic of broncho-pneumonia. 

38 



498 



DISEASES OF THE RESPIRATORY SYSTEM. 



The chart shown in Fig. 84 is that of relapsing pneumonia. The first 
attack was fairly typical, with about the usual duration. Resolution 



107° 
100° 
105° 
104° 
103° 
102° 
101° 
100° 
09° 


1 


2 


3 


1 


5 


6 


7 


s 


9 


10 


1.1 


12 


13 


ii 


15 


16 


17 


18 


19 


20 


21 


'.'2 


23 


24 


25 


20 


27 2 


8 29 


30 


31 


32 


































































































































\ 


A 


A 




i\ 




1 


It 


A 








/ 




















A 














t 


^ 




\l\ 




/ 


f 


A 


/ 


ft 


\ I 


A 






\ 1 








h 






A 




f 




X 












\ 








\ 




/ 


/ 




sT 


\ 


\H 




V 1 


\ 






/ 


"A 




/ 








JJ_ 


















V 


/ 


V 


V 


V 


V 




V 


V 




J 




\ 




/ 


\ 




/ 


i 


I 


fl 














\ 




























V 










\ 


/ 




V 


\ 


tx 














































V 






u 










V : _, 




98° 

































































Fig. 83. — Temperature curve of broncho-pneumonia with, a prolonged course ; recovery. 

History. — Female, eighteen months old ; in fair condition ; sudden onset. Early signs were 
localized, line rales over left base ; on fifth day signs of consolidation at left base, with rales on 
both sides behind. General symptoms of moderate severity. Signs of consolidation disappeared 
about a week after cessation of fever; rales persisted nearly two weeks longer. 

had begun, and was apparently progressing favourably, when there was a 
return of the fever, accompanied by new signs in the chest, the second 



107° 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 


16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 


33 34 


106° 






105° . 


, -A 




104° . J _A^J _i —J. 


w 




103° /Inu Jftw 7 a f A 


LI . ^ A 




102° t& y \r ±v\t t jrht 


\TT\ Kitf i 




101° v v v l v v LL\L a 


iztttp trt 




tr^t\hK 


M/ \ t 




99° t^ff^ r 


/ 


98° V 


^r- 2^^ 



Fig. 84. — Temperature curve of relapsing broncho-pneumonia : recovery. 

History. — Male, nineteen months old ; delicate. Consolidation on sixth day in left lower lobe 
behind ; two days later small area of consolidation in right lower lobe behind ; many rales both 
sides ; eighteenth day, signs of consolidation had disappeared, but many rales persisted. Acces- 
sion of fever on nineteenth and twentieth days, accompanied by extension of disease as shown 
by new rales, but no evidences of consolidation during second attack. Slow resolution and con- 
valescence. 

attack being shorter and milder than the first. Very often the tempera- 
ture falls to normal without any signs of resolution, and after an interval 
varying from two or three days to a week there is recurrence of the fever 





1 


2 


3 


1 


5 


<i 


7 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 


— 




















/ 






1 


1 


I 


j 


/ 






\ 






\ 


V 












/ 








\ 


\ 




V 




— 


— 


V 























Fig. 85. — Temperature curve of broncho-pneumonia; fatal. 

History. — Male, six months old ; markedly rachitic ; sudden onset. Signs first day were fine 
moist rales throughout the chest, marked prostration, and cyanosis; on third day, a small area 
of consolidation in upper lobe of left lung behind ; increasing prostration, cyanosis, and death. 
Autopsy. — No pleurisy; consolidation at left apex behind, and posterior two thirds of left lower 
lobe ; consolidation of right apex posteriorly, lower lobe intensely congested. 



ACUTE BRONCHO-PNEUMONIA. 499 

and other constitutional symptoms, the second attack frequently proving 
fatal. 

A frequent course in fatal cases is shown in Fig. 85. The duration of 
the disease, instead of being five days as in this case, is often only three or 
four. The temperature at first fluctuates widely, then rises gradually 
until death. 

Duration of the fever. — The following figures give the duration of the 
fever in 231 cases. The majority were primary ; none were secondary to 
diphtheria, and only a few complicated measles. Of the 169 cases that 
were fatal — 

There died during the first six days 25 • per cent. 

" " between the seventh and twenty-first days. .. . 55-5 " 
" " " li twenty-first and sixtieth days. .. . 19 -5 " 

100-0 " •• 

Of 78 cases which recovered, the duration of the fever was — 

Less than seven days 11 "5 per cent. 

From seven to twenty-one days fi6-6 " 

From twenty- one to ninety days 21 • 9 " 

100-0 " " 

Physical Signs. — In considering the signs of broncho-pneumonia, it is 
better to connect them with the different conditions in the lung than to 
group them in stages, as in lobar pneumonia. 

(a) Without consolidation. — It can not too often be repeated that 
broncho-pneumonia may exist without signs of consolidation at any period 
during the course of the disease. When the attack is primary, the ear- 
liest signs are due to congestion of the lung, associated with bronchitis 
of the fine tubes, which is usually localized, but which may be general. 
If the disease has followed bronchitis of the large tubes, its signs arc 
added. Congestion of the lung gives feeble breathing over the affected 
area, and occasionally slight dulness or diminished resonance. With this 
are found coarse sonorous, and finer sibilant rales, due to congestion and 
swelling of the mucous membrane of the larger and smaller bronchi re- 
spectively. These signs are soon replaced by very fine moist rales, which 
are usually localized in one of the lower lobes behind (Fig. 86). These 
localized fine rales are the first distinctive sign of broncho-pneumonia. 
Soon a change in the respiratory murmur is heard in the affected area, 
becoming feebler in intensity and higher in pitch. Elsewhere in the chest 
there may be coarse rales, due to bronchitis of the large tubes. In Buch 
cases the areas of pneumonia are so small and BO scattered as to give in 
themselves no additional signs, and the case may go on to recovery with- 
out presenting anything more distinctive than the signs mentioned. 

(b) With areas of partial consolidation.— In the lung at this time 
there are small areas of consolidation, generally superficial and separated 



PHYSICAL SIGNS OF BKONCHO-PNEUMONIA. 




Fig. 86. — First stage. Coarse rales over both lungs ; 
localized fine (subcrepitant) rales at the left 
base. No change in breathing sounds. 



Fig. 87. — Second stage. Coarse and fine rales over 
both lungs behind; at left base an area of 
partial consolidation, with broncho-vesicular 
breathing, exaggerated voice, and very sharp 
rales. 




Fig. 88.— Third stage. A larger area of partial 
consolidation, and in the centre a small area of 
complete consolidation, with bronchial breath- 
ing and voice and slight dulness. Signs over 
the right lung similar to what were previously 
present over the left. 



Fig. 89. — Fourth stage. Extensive disease of both 
sides; large area of complete consolidation on 
the left, with dulness, bronchial breathing and 
voice, and no rales ; surrounding this, broncho- 
vesicular breathing, with many rales. Signs 
in the right lung "similar to those previously 
present over the left. 



Note.— The disease may stop at any one of these stages and resolution take place. 



500 






ACUTE BRONCHO-PNEUMOXIA. 



501 



by healthy or congested lobules. Percussion in these cases usually gives 
negative results, but sometimes there is very slight dulness. The vocal 
fremitus is not usually altered. The fine moist rales may be heard over 
quite a large area, but at some point, usually near the spine, over one of the 
lower lobes, they are sharper, louder, higher pitched, and seem close under 
the ear (Fig. 87). Kespiration is feebler here than elsewhere, and broncho- 
vesicular in quality, approaching bronchial breathing more and more as 
the consolidation increases. The resonance of the voice and cry is exag- 
gerated. 

(c) With areas of consolidation more or less complete. On percussion 
there is dulness, but surprisingly little in comparison with the other signs 
of consolidation present. It is due to the fact that the consolidated por- 
tion, though extensive, is superficial, and does not involve the lung to any 
great depth, and also that there are in the consolidated area many alveoli 
which still contain air (Plate XII). On palpation there is usually a slight 
increase in the vocal fremitus. On auscultation, there are still present the 
evidences of bronchitis, usually only behind, but sometimes over the entire 
chest, Coarse and fine rales are intermingled. Over the consolidate! 1 
parts are heard bronchial breathing and bronchial voice. At the centre 
of these areas the bronchial breathing is pure and rales are usually absent, 
but at the margin rales are present and the breathing approaches the 
broncho- vesicular type (Fig. 88). The signs of consolidation thus air 
rarely sharply circumscribed as they are in lobar pneumonia, but shade off 
gradually. The consolidated area is at first small, usually in one of the 
lower lobes near the spine, but may gradually extend until nearly the 
whole of one or even both lungs behind are more or less completely solidi- 
fied (Fig. 89). The signs are found as far forward as the axillary line, 
but usually stop here. Friction sounds may be heard over the consolidated 
areas, but very rarely except where signs of complete consolidation are 
present. It is often impossible to obtain any idea of the condition of an 
infant's lung during quiet, superficial respiration. Sometimes over ;i pari 
which is completely consolidated there is heard only very feeble breathing, 
or the lung may be almost silent. If, however, the child he made to cry 
or to take a deep inspiration, both the bronchial breathing ami rales are 
distinctly brought out. The intensity of the consolidation increases as 
the case advances, and the Bigns hecome more and more like those of lobar 
pneumonia. During resolution there is first a disappearance of the signs 
of consolidation, which may he quite rapid, but friction sounds and rales 
of all kinds often persist for three or four weeks longer. 

The following statistics are of some interest, as Bhowing the frequency 
with which signs of consolidation were found, and the day when they were 
discovered. Their value is increased by the fact that the children were 
under observation in an institution at the time they were taken Bick, and 
that in all the fatal cases— thirty-six in number— in which Bigns of con- 



502 DISEASES OP THE RESPIRATORY SYSTEM. 

solidation were absent, the diagnosis of pneumonia was confirmed by 
autopsy : 

Consolidation noted on or before the fourth day 47 cases. 

" " from the fifth to the seventh day 36 " 

" " " the eighth to the twelfth day 12 " 

" after the twelfth day 9 " 

No signs of consolidation 62 " 

166 " 

In general, it must be borne in mind that in many cases signs of con- 
solidation are never present, as the areas of pneumonia are small and 
widely scattered ; that where there is consolidation it is usually incom- 
plete, because there are small areas of healthy lung tissue between the 
hepatized portions ; that the signs of consolidation usually shade off 
gradually ; and that both sides are almost invariably involved, although 
one side usually to a greater degree than the other. 

(4) The protracted form. — Persistent broncho-pneumonia. — This is 
seen in primary cases, especially among delicate children, and it is not 
uncommon in pneumonia complicating pertussis. The onset and course 
of the disease for the first two or three weeks do not differ from an ordi- 
nary attack of moderate severity, but at the end of this period there is seen 
no tendency in the process to subside. The fever continues, but it is not 
high, and by physical examination it is found that the areas of consolida- 
tion are gradually increasing day by day, until sometimes the greater part 
of both lungs behiud are involved. The air vesicles become so distended 
with cells that the signs of consolidation are more complete than in ordi- 
nary broncho-pneumonia. There is marked dulness, sometimes almost 
flatness ; bronchial breathing is exaggerated in intensity, until it resem- 
bles cavernous breathing, and it may be impossible to distinguish between 
them. However, the fact that it is heard over so large an area, that it 
shades off gradually, and that it is accompanied by friction sounds, usually 
make a distinction possible. 

The temperature in these protracted cases for the first two or three 
weeks is from 100° to 105° F. ; but after this time it is generally lower 
—from 100° to 102° or 103° F. The course is not at all regular, but 
marked by frequent exacerbations and remissions. The general symptoms 
are those of progressive asthenia. There are continued wasting, anaemia, 
and steadily increasing prostration. The appetite is lost, often there is 
an aversion to food, and vomiting is easily excited if food or stimulants 
are forced. The stools show that even what food is taken is very imper- 
fectly digested and assimilated. The skin becomes dry, and loses its elas- 
ticity ; bed-sores may form ; fine punctate haemorrhages are seen over the 
abdomen, sometimes over the chest and extremities. The latter is always 
a very bad symptom, and I have never seen recovery where it was present. 

The chart in Fig. 90 is typical of the course of one of these protracted 



ACUTE BRONCHO-PNEUMONIA. 



503 



cases terminating fatally. The temperature shows four distinct exacer- 
bations. 

Death takes place from slow asthenia, usually after five or six weeks, 
but the attack may be prolonged for eight or ten weeks. The general 



107 

IOC 

104' 

1 

102" 

101" 

GO- 


12 3 4 6 7 8 


9 10 11 12 1 J 14 l:. 10 17 1; V-oi'ii'. 2, 24 -" -•, .7 2- i'.< ;'. 01 02 i- U 35 30 37 38 39 


-10 4142 40 H45-J047 48«'50'51 






















| , 


~u 








/ iM ^_t 


-*-A -I-'JU -4- 








M J^Lr 


^\ \ . K i A A 


/ J_J; A-J1_l_ 


A 




-Wftfr 


fftA W&inh-k-. 


Pm\m^-m\U^\^^-\\ , 


rill 


1 i I T i i ■ i lA/WW/ ! • ■ v ' v, / y ' v " w 


BS' 


1 1 


1 M 1 ! i M M v 



Fig. 90. — Temperature curve of persistent broncho-pneumonia, terminating fatally. 

History. — Male, two and a half years old; healthy; sudden onset; for two weeks the only 
signs were very fine moist rales throughout both lungs, front and back. The rales in front in 
great part gradually cleared up ; those behind persisted, but it was not until the thirty-fourth day 
that positive signs of consolidation were discovered in the left lower lobe behind; these signs 
gradually extended, and, before death, were present over nearly the whole left lung behind and 
over the right lower lobe. There were also friction sounds over both lungs. Autopsy. — Old and 
recent pleurisy with general adhesions; left lower lobe completely solid, patches of consolida- 
tion in left upper lobe. Eight lower lobe about one half consolidated, with patches elsewhere. 
Bronchial glands large, but not cheesy. No evidence of tuberculosis upon either gross or micro- 
scopical examination (see Fig. 81). 



symptoms, the temperature, and the wasting strikingly resemble cases of 
tuberculosis, and such is the diagnosis often made. 

Although the majority of the cases in which the fever lasts over four 
weeks run the fatal course just described, such apparently hopeless cases 
occasionally recover. The temperature gradually falls lower and lower, 
until it remains at the normal point. For some time after this, often two 
or three weeks, little change can be seen, either in the general Bymptoma 
or in the physical signs. Gradually the appetite returns, the child is 
brighter and begins to take an interest in its surroundings, the cough 
abates, and little by little the signs in the lungs clear up, and the case 
may go on to complete recovery. Convalescence, however, is always slow, 
and may be interrupted by relapses, it being many months before health 
is fully restored. Although the signs of consolidation disappear in a few 
weeks, rales are apt to persist for a much longer time. It is probable in 
such cases, even though all signs of disease disappear from the chest, that 
the lung does not become quite normal, and relapses and second attacks 
are always possible. The general health may be so undermined that the 
child never regains his former vigour; yet in a surprising number of 
these cases recovery seems to be complete. 

5. Secondary pneumonia : (a) Complicating pertussis, [t is not often 
that pneumonia develops during the first two weeks of this d 
most frequent time is from the third to the fifth week, when the patient 
has become exhausted from the previous severity of the pertu 
thirds of my cases the development of the pneumonia was gradual, follow- 
ing bronchitis of the larger tubes. The temperature chart Bhown in 
91 illustrates well this course. 



504 



DISEASES OF THE RESPIRATORY SYSTEM. 



When the onset is sudden, the symptoms do not differ essentially from 
those of primary pneumonia. The temperature of pertussis-pneumonia is 
usually low, in a very large number of cases not rising above 103-5° F., 
and ranging most of the time from 101° to 103° F. These cases are very 
apt to be prolonged, the fever often lasting for three or four and some- 



10?° 
106° 
105° 
10±° 
103° 
102° 
101° 
100° 
99° 


1 


2 


3 


1 


5 


6 


7 


8 


9 


10 


ii 


12 


13 


ii 


15 


16 
































































/ 






























i 1 
































/ 




















A 








\** 






















r 


\/ v 






















/ 


\ , 


J 


V 
























\ 


J 


v 


















98° 












V. 




V 



















Fig. 91. — Temperature curve of fatal broncho-pneumonia, complicating pertussis. 

History. — Male, six months old ; delicate ; pertussis for three weeks. Early signs of bron- 
chitis of large tubes only ; on the eleventh day signs of consolidation in right upper lobe. In- 
creasing prostration, cyanosis, and death. Autopsy. — Large areas of consolidation in right middle 
and upper lobe, small scattered spots throughout left lung. 



times even for six weeks. The physical signs of consolidation may per- 
sist for a long time after the temperature has become normal, and yet 
the case may recover entirely. I have seen one case in which complete 
recovery occurred after the signs of consolidation had persisted for six 
months, and another in which they had persisted for over eight months. 
A r ery often the signs continue during the entire attack of pertussis. 
Cerebral symptoms are common, especially toward the close of the disease. 
Of fifty-four fatal cases twenty-five had convulsions, and in twenty-two 
this was the mode of death. Only one case which developed convulsions 
recovered. 

(b) Complicating measles. — In a small number of cases the pneumonia 
begins simultaneously with the invasion of measles, but generally not until 
the eruption appears. Instead of gradually falling to normal with the 
fading of the eruption, the temperature continues high. Any of the 
clinical types of primary pneumonia may occur in measles, the acute con- 
gestive variety which is fatal in two or three days, being especially com- 
mon. In its course and duration the pneumonia of measles resembles 
the severe form of primary pneumonia. The broncho-pneumonia of scar- 
let fever differs in no way from that of measles. 

(c) Complicating diphtheria. — In many cases this does not give a dis- 
tinct clinical picture of its own, its symptoms being mingled with those of 
diphtheritic bronchitis, with which it is frequently associated. In others the 
forms resemble those seen in measles. The majority of cases occur as a 
complication of diphtheria of the larynx, although it is not infrequent in 
the septic cases in which only the upper air passages are involved. Pneu- 
monia developing after laryngitis is usually seen within two days from 



ACUTE BRONCHO-PNEUMONIA. 595 

the beginning of laryngeal symptoms, and runs a very rapid course. In 
rare cases it may develop as late as the middle or end of the second 
week. When it complicates diphtheritic bronchitis, pneumonia is recog- 
nised by the high temperature, rapid breathing, and increased prostra- 
tion, much more certainly than by the physical signs, which are always 
obscured by the laryngeal sounds. Percussion may aid in the diagnosis 
of consolidation where the signs on auscultation are doubtful. In the 
early cases, death usually occurs before the disease has advanced far 
enough to give the physical signs of consolidation, but in the late pneu- 
monia, which develops more slowly, these may be present. 

(d) Complicating influenza. — Without doubt many cases regarded as 
primary are really secondary to influenza, particularly when that disease 
is prevailing, for very often the pneumonia of influenza differs in no 
essential points from the primary form. There are, however, two types 
which are quite characteristic. In the first, high temperature and pros- 
tration exist for several days before there are any physical signs of pul- 
monary disease, and often before there are any symptoms pointing defi- 
nitely to the lungs. Pneumonia may then develop and run its usual 
course. The second variety are the cases of short duration often lasting 
but three or four days, and sometimes only two, but with excessively high 
temperature and very severe general symptoms. 

(e) Complicating ileo-colitis. — This is usually a somewhat subacute 
form of pneumonia, which is scarcely recognisable except by the phys- 
ical signs. It is seen in the protracted cases of ileo-colitis, usually of the 
ulcerative variety, and occurs late in its course. The temperature is not 
high. Cough, pain, and dyspnoea are slight or entirely wanting. Accel- 
erated respiration is frequently the only symptom suggestive of pulmo- 
nary disease. By physical examination there are found the usual Bigns, 
generally involving both lungs posteriorly. Very often pneumonia is 
not suspected during life, the constitutional symptoms being sufficiently 
explained by the intestinal lesions, although the autopsy discloses the fact 
that death was due to pneumonia. 

Complications. — Those relating to the lungs have been described with 
the lesions. Pleurisy will be separately considered. Emphysema can 
rarely, and abscess and gangrene never, be recognised by the physical 
signs. 

Purulent meningitis may complicate acute broncho-pneumonia. It 
was met with twice in one hundred and seventy autopsies. [1 is in all 
respects similar to that occurring with lobar pneumonia. Meningeal 
hemorrhage was seen only once, and was the cause of death in a patient 
eleven months old, who a few days before was Beized with convulsions, fol- 
lowed by a gradually increasing stupor, which continued until death; 
The haemorrhage covered the entire convexity of the I train. Endocar- 
ditis is extremely rare ; it was not observed in any of my cases. Acute 
39 



506 DISEASES OF THE RESPIRATORY SYSTEM. 

pericarditis was seen but twice, in both cases complicating pneumonia of 
the left side. Complications referable to the digestive tract are quite 
common. Herpetic stomatitis is frequent, and occasionally the ulcerative 
variety is 'seen. Thrush often occurs in the protracted cases among 
very young infants. Gastro-enteritis is not very common, considering 
the frequency of vomiting and diarrhoea, these depending usually upon 
functional derangement. In only three of my cases was there nephritis. 
In all it was of the acute exudative variety, and in only one case was it 
severe enough to affect the prognosis. 

Old lesions of tuberculosis, cheesy nodules in the lungs and sometimes 
in the pleura, are not infrequently met with in patients dying of acute 
pneumonia of a non-tubercular character. 

Diagnosis. — An acute onset with continuous high fever, rapid respira- 
tion, and cough, should always lead one to suspect pneumonia. When 
to these symptoms are added prostration and cyanosis, the diagnosis of 
pneumonia is almost certain. Cases of the acute congestive type are 
the ones most frequently unrecognised, and in many of these cases a posi- 
tive diagnosis is impossible during life. Many atypical cases of pneumo- 
nia are seen, particularly in young infants. An unusual temperature 
course is perhaps the symptom most likely to lead to a mistake. While 
this, as a rule, is high and remittent, it is sometimes not so, and may be 
but little above normal. Rapid respiration is almost always present, but 
cough may be very slight, especially in infants. In very young infants, 
the diagnosis often rests upon the prostration, cyanosis, and rapid respi- 
ration, the other acute inflammatory symptoms being absent. Only the 
physical signs of the disease can positively settle the question of diagnosis. 

When pneumonia follows bronchitis of the large tubes, whether the 
bronchitis is primary or complicates one of the infectious diseases, the 
extension of the disease to the lungs is usually marked by three symptoms 
— a steadily rising temperature, more frequent respiration, and increasing 
prostration. It may be twelve or twenty-four hours before the change is 
indicated by the physical signs. 

The diagnosis of broncho-pneumonia from congenital atelectasis has to 
be considered only during the first three or four months, it being rare for 
atelectasis to give symptoms after this time. In early infancy the danger 
of confusing the two is increased by the fact that atelectasis and broncho- 
pneumonia may be associated. If the infant has been strong and well for 
the first two months, congenital atelectasis can be excluded. It is likely 
to be found in delicate infants, where there is a history of difficulty in 
resuscitation at birth and feeble cry during the early days of life. The 
temperature is low, often subnormal, the cyanosis is out of proportion to 
the other symptoms, and the physical signs are doubtful or absent. 

At the outset, pneumonia can not be positively diagnosticated from 
severe bronchitis. Such a bronchitis often begins with severe pulmonary 



ACUTE BRONCHO-PNEUMONIA. 507 

symptoms and a temperature of 103° or 104° F. ; but this high tempera- 
ture is of short duration, usually falling after twenty-four or forty-eight 
hours to 100° or 101° F. The prostration is much less, and all the symp- 
toms, possibly excepting the cough, less severe. The only physical signs 
are coarse rales, which are heard throughout the chest. 

The same rules apply to bronchitis of the smaller tubes. The rales are 
heard both in front and behind, and usually over both sides. If with such 
rales the temperature continues to rise for three days in succession above 
103° F., it may be assumed that pneumonia is present, provided there 
is no other disease which might explain the temperature. If, instead 
of being generalized, the signs of bronchitis are limited to a single lung, 
or to one lung posteriorly, the existence of broncho-pneumonia may be 
regarded as certain. Localized bronchitis, then, is always to be inter- 
preted as broncho-pneumonia, provided tuberculosis can be excluded. In 
doubtful cases the chances largely favour broncho-pneumonia rather than 
bronchitis. Attention is again called to the fact already mentioned, 
that there are a large number of cases of pneumonia without signs of 
consolidation. 

The differential diagnosis of broncho- from lobar pneumonia will be 
considered in connection with the latter disease. On account of the remit- 
tent temperature, broncho-pneumonia may be confounded with malarial 
fever; if with the latter there is some bronchitis, or if accompanying the 
onset of a severe malarial paroxysm there is pulmonary congestion — two not 
infrequent combinations — the difficulties are increased. A positive diag- 
nosis is often impossible except by careful observations of the temperature 
for one or two days. The points of differentiation are, that the tempera- 
ture of pneumonia, though often remittent, is very rarely intermittent, and 
that it is not affected by quinine. In addition, the characteristic features 
of malaria — enlargement of the spleen, the plasmodium in the blood, and 
a history of exposure — must, of course, be taken into account, 

Both the acute and the persistent forms of simple broncho-pneumonia 
may be confounded with the tubercular form ; the points of distinction are 
considered in the chapter on Tuberculosis. 

Prognosis. — Broncho-pneumonia is always a serious disease, and in an 
infant dangerous to life. The prognosis depends upon the age, surround- 
ings, and previous condition of the patient, upon the nature of the in- 
fection, whether the disease is primary or secondary, and, if the latter, 
upon the character of the primary disease. In private practice the mor- 
tality from broncho-pneumonia is from lo to 30 per cent, depending upon 
the conditions mentioned. One whose knowledge of broncho-pneumonia 
is derived from observations in private practice can, however, form but 
little idea of the frequency and severity of this disease in hospitals and 
asylums for infants and young children, particularly when it occurs with 
epidemics of measles, diphtheria, and pertussis. The statistics in the Pol- 



508 



DISEASES OF THE RESPIRATORY SYSTEM. 



lowing table are taken from the records of two institutions with which I 
am connected, and fairly represent the results seen in such places in chil- 
dren under three years : 



Forms of Pneumonia. 



Primary broncho-pneumonia 

Following bronchitis of the large tubes, 
Secondary to measles 

" pertussis 

" scarlet fever 

" diphtheria 

" ileo-colitis 

" epidemic influenza 

" varicella 

" erysipelas 



Totals. 



Cases. 



194 
29 



7 
47 
19 

6 

2 
2 



461 



Deaths. 



19 
56 
54 

7 
47 
18 

1 

2 
2 



302 



Percentage 
mortality. 



49-4 

65-5 

62-9 

81-8 

100-0 

100-0 

94-7 

16-6 

100-0 

100-0 



65-5 



The mortality varies directly with the age of the patient, being the 
highest during the first year, and diminishing steadily thereafter, as shown 
by the following table giving the result in three hundred and forty-five 



cases : 



Age. 


Cases. 


Percentage 
mortality. 


During: the first year 


202 

102 

33 

6 

3 


66 


second vear 


55 


" " third year 


33 


" " fourth year 


16 


" " fifth year 









In this table are included no cases secondary to measles, scarlet fever, 
or diphtheria. 

Probably the best of all guides to the nature and virulence of the in- 
fection is the temperature. An excessively high temperature indicates a 
virulent type of infection. Some idea of this may be gained from these 
figures, giving the highest temperature and the mortality in two hundred 
and thirty-one cases, not including cases with measles or diphtheria : 



Highest Temperature. 


Cases. 


Deaths. 


Percentage 
mortality. 


106° F. or over 


55 
94 
53 
22 

7 


47 
56 
26 
13 
5 


85-5 


105° or 105-5° 


60-0 


104° or 1045° 


49-0 


102° to 103-5° 


60-0 


995° to 101-5° 


71-0 







The high mortality of the cases with unusually low temperature is due 
to the fact that they nearly always were seen in infants with very feeble 



ACUTE BRONCHO-PNEUMONIA. 509 

vitality. Cases with a steadily high temperature — between 102-5° and 
104° F. — usually do better than those with wide fluctuations, such as 100° 
to 105 -5° F. The probable explanation of this is, that the former are 
due to the pneumococcus, while the latter are apt to be cases of mixed 
infection, or due to the streptococcus. As a rule, the danger of the disease 
increases steadily with every degree of temperature above 104*5° F. 

An important factor in the prognosis is the previous condition of the 
patient. One of the most unfavourable is rickets, both on account of the 
feeble muscular power of these children and their thoracic deformities. 
Any condition which diminishes the general vitality increases the danger 
from broncho-pneumonia. As a rule, second attacks are more serious than 
the primary ones, especially if the interval between them is short. 

In making the prognosis in any given case, the symptoms to be con- 
sidered are the height and course of the temperature, the presence or 
absence of nervous symptoms, the condition of the organs of digestion, 
the presence of cyanosis and the extent of the disease as shown by the 
physical signs. 

Nervous symptoms early in the disease do not affect the prognosis. 
Three cases in which convulsions occurred at the onset all recovered, but 
of thirty-seven cases in which convulsions occurred at a late period during 
the course of the disease, all but one proved fatal. 

So long as the food is well taken and retained and the stools show 
that it is being assimilated, no case is hopeless, no matter how severe the 
other symptoms may be; but the existence of vomiting, diarrhoea, or 
severe indigestion makes the issue doubtful, even though the other symp- 
toms are very favourable. These conditions are especially important in 
protracted cases, where death is usually due to slow asthenia. 

Treatment. — The most important part of prophylaxis is to give careful 
and early attention to every attack of bronchitis in an infant, for everj 
such attack should be regarded as a possible precursor of pneumonia. It 
is striking that one sees broncho-pneumonia so seldom in private practice 
among the better classes, even though bronchitis is very frequent ; while 
among hospital and dispensary patients, where bronchitis is v.tv often 
neglected, broncho-pneumonia is constantly seen. The question of isolat- 
ing cases of pneumonia is one which is lately becoming more and more 
important. While it may not often be the case thai primary pneumonia 
is due to contagion, there seems to be little doubt that this isal timea true 
of the pneumonia secondary to measles and diphtheria. Twice in one insti- 
tution have I seen regular epidemics of broncho-pneumonia occur with 
outbreaks of measles— in some of the wards nearly every case of mi 
developing pneumonia. In another institution, during one entii 
(1888-89), almost every case of diphtheria transferred to a certain isola- 
tion pavilion developed pneumonia, and died from thai complication. 
Cases of measles and diphtheria which are complicated by pneumonia 



510 DISEASES OF THE RESPIRATORY SYSTEM. 

should, if possible, be carefully isolated from others, aud wards in which 
they are treated should be thoroughly disinfected before they are used 
for simple cases. 

The hygienic treatment of pneumonia is important, and usually it 
receives too little attention. The child should be kept in a large, well- 
ventilated room, preferably one with an open fire ; if possible, being 
changed from one room to another two or three times a day, to allow 
thorough airing. Nothing is more important for an infant sick with 
acute pulmonary disease than plenty of oxygen. Older children should 
be kept in bed. Infants for a considerable part of the time may be held 
in the nurse's arms. A frequent change of position in all cases is essen- 
tial; no child should be allowed to lie for hours directly on the back. 
The general rules for feeding all sick children (page 190) should be fol- 
lowed here. As a rule, neither stimulants nor medicine should be adminis- 
tered in the food. 

The same local treatment may be employed as in cases of bronchitis 
(page 467). The oiled-silk jacket should be worn throughout the attack, 
and counter-irritation maintained by the use of the mustard paste. Hot 
poultices of flaxseed may be employed occasionally, but never continuously. 

Emetics. — What was said of expectorant mixtures and emetics in the 
treatment of bronchitis applies here with even greater force. In infants 
both had better be omitted altogether. 

Stimulants. — Alcoholic stimulants are needed in all secondary cases, 
and in a large proportion of those which are primary. No doubt they have 
been greatly abused, and, when pushed in the early stage, often do much 
harm ; but in most of the severe cases they are indispensable. They are 
usually needed from the outset, where the pneumonia is secondary to 
measles, diphtheria, scarlet fever, or other infectious diseases. They are 
called for when the pulse is weak, compressible, rapid, and irregular. 
Whisky or brandy is usually to be preferred, although the taste of the 
patient often has to be consulted, and when these are refused, some wines, 
like sherry or tokay, may be readily taken. (For methods of adminis- 
tration see page 49.) The dose is to be regulated by the condition of the 
patient. From one half to two ounces daily may be given to an infant of 
one year. It is rarely advisable to go above this limit except for a few 
hours at a time at critical periods ; then two or three times as much 
may be used. Contrary to the statement of many writers, these stimu- 
lants are usually well borne, even by young children. Stimulants are 
most needed when the temperature is low, or falls suddenly, as at the 
crisis of the disease. When the temperature is high, smaller amounts are 
generally required. 

In many cases strychnine is even more valuable than alcohol. Usually 
they should be combined, as the indications are the same. Where the 
dose is to be repeated every three hours, r J-g- of a grain is as much as it is 



ACUTE BRONCHO-PNEUMONIA. 51 1 

wise to give to an infant a year old. This may be kept up for days, and 
for a shorter time larger doses may be given, the effect always being 
carefully watched. For older children digitalis may be used, but I have 
rarely seen much benefit from it in infants. In attacks of heart failure 
associated with pulmonary congestion, nitroglycerin should be given — 
gr. g-J-g- every hour for four or five doses, or even longer. 

Kespiratory stimulants are needed in most cases, even more than are 
cardiac stimulants, but we have none which can be wholly depended upon. 
For a short time, atropine gr. -^J-^, caffein gr. ^ or strychnine gr. -j-J-q-, 
may sustain a child with sudden failure of respiration, but in the slow 
respiratory failure that results from exhaustion their effect is but tem- 
porary. The doses mentioned are for an infant of one year. The drugs 
may be used successively or together ; for immediate effect they should 
be given hypodermically. Oxygen may be classed with the respiratory 
stimulants. It should be given continuously, but always freely mixed with 
atmospheric air. A good method is to place the child in a half-open tent, 
beneath which the gas is introduced. Gentle friction of the chest Avail, 
without disturbing the patient, is sometimes useful in stimulating the 
respiratory muscles, especially in protracted cases. 

Antipyretics. — It must be remembered that the normal range of tem- 
perature in broncho-pneumonia is from 101° to 104*5° F. This tempera- 
ture is not in itself exhausting, and the chances of recovery are not, I 
think, improved by systematic efforts at reducing it so long as it re- 
mains within these limits. Too much can not be said in condemnation 
of the practice of giving such drugs as phenacetine, antipyrine, and anti- 
febrine in full doses for the reduction of temperature. In small doses 
they are often useful to allay nervous irritability, restlessness, and pro- 
mote sleep. Quinine can not be considered an antipyretic in pneumonia 
except incases complicated by malaria. Otherwise it does little if any 
good, and often great harm, by disturbing the stomach. 

Antipyretic measures are indicated in cases of hyperpyrexia, which we 
may define as 105° F. or over, or when extreme nervous symptoms exist, 
even though the thermometer may not register the decree mentioned. 
Under these circumstances, the most certain, the most within our control, 
and hence the safest antipyretic, is cold. It may be u^vd by the gradu- 
ated bath, the cold pack (pages 47, 48), sponging, or an icte-bag applied to 
the chest. 

The most convenient and efficient methods of using fold are the hath 
and the cold pack— the bath for infants, and the pack for older children. 
The peripheral circulation should be closely watched, and maintained by 

friction of the body during the bath, and the application of heal to tl \- 

tremities immediately after it. In most cases the hath should be preceded 
by stimulants. The effects are often rerystriking ; when there have been 
a flushed face, hot dry skin, extreme restlessness, and muscular twitchii 



512 DISEASES OP THE RESPIRATORY SYSTEM. 

all these symptoms may subside rapidly and a quiet sleep follow. The 
bath should be repeated as soon as these symptoms return, whether the 
thermometer has risen to its former height or not. When with hyper- 
pyrexia we have general cyanosis, cold surface, feeble pulse, shallow respi- 
ration, and stupor, cold is contraindicated and a hot mustard bath should 
be used. 

Inhalations. — These are of more value in relieving cough and in pro- 
moting bronchial secretion than any other means we possess. At the same 
time, they seem often to have a beneficial influence upon the local process. 
They are useful in proportion to the amount of bronchitis which is pres- 
ent. The same substances are to be used, and in the same way as men- 
tioned in the article on Bronchitis. 

The nervous symptoms, restlessness, loss of sleep, etc., are often best 
controlled by cold or tepid sponging ; in other cases by small doses of 
phenacetine — i. e., one grain every two hours to a child of six months. 
Opium is to be avoided unless there is severe pain, which is very rare ; 
or, when the incessant cough is not relieved by inhalations. Dover's 
powder is the preparation to be preferred, and an occasional dose of a 
quarter of a grain usually all that is necessary. 

Sudden attacks of general collapse with cyanosis are frequent in severe 
cases of broncho-pneumonia. They may come on at any period in the 
disease. When occurring in the early stage, if promptly and energetically 
treated, recovery may take place, but when they come on in the late 
stages they are usually fatal. They may be due to acute congestion or 
oedema of the lung not previously involved. The most efficient treatment 
is to put the child into a hot mustard bath (page 54), to use strychnine 
and nitroglycerin hypodermically, and to give oxygen continuously. For 
a few hours alcohol should be given ad libitum. Nitrite of amyl is some- 
times more efficient than nitroglycerin, because of its almost instantaneous 
effect. I must confess to have seen very little benefit from the use of 
camphor, although many excellent observers esteem it very highly. 

Treatment of protracted cases. — Where the fever continues for five 
or six weeks, with no disposition on the part of the disease to subside, 
about all that can be done is to continue the sustaining treatment adopted 
in the earlier part of the disease — careful feeding, judicious stimulation, 
and proper hygienic means. Many of these cases will recover if the pa- 
tient's strength holds out; but, unfortunately, in the majority the continu- 
ance of the pneumonic process is in itself evidence of the weakened vital- 
ity of the patient, and, though he may live a long time, the attack proves 
fatal in the end. 

Where the fever has disappeared, and there is only a persistence of 
the physical signs and the general cachexia, the Qases are more hopeful. 
Here, a change of air is more important than all other means of treatment. 
If in the winter or spring the child can be removed to a warm, dry cli- 



ACUTE BRONCHO-PXEUMONIA. 513 

mate where it can be kept in the open air, or if, in the summer, it can be 
taken to the mountains, immediate improvement is often seen, followed 
by rapid recovery. This experience we see repeated every year with hos- 
pital patients when they are transferred from the city to the country 
in May or June. With the change of air a general tonic plan of treat- 
ment should be followed, cod-liver oil, arsenic, iron, and quinine being 
used, according to the indications in each particular case. 

In specific drugs to promote resolution I have no faith. Where the 
cough continues, creosote may be used both internally and by inhalation, 
as after bronchitis. One should never declare one of these cases of pro- 
tracted pneumonia to be hopeless, nor should he be too ready to assume 
that tuberculosis is present because the child is wasted and anaemic, and 
the physical signs have persisted. In private practice the cases of simple 
protracted pneumonia outnumber the tubercular ones, three to one. 

Summary. — In the treatment of broncho-pneumonia it should be 
borne in mind that, while very little can be done for the disease, very 
much can be done for the patient. The hygienic measures generally 
grouped under the term " careful nursing " are of great importance, and 
many of the mild cases need no other treatment. In severe cases, the 
patient may be in great danger in the early stage from two causes : first, 
from the intensity of the general infection, which is best combatted by the 
use of alcohol and strychnia ; and, secondly, from the mechanical embar- 
rassment of the heart and respiration, in consequence of the sudden inter- 
ference with the function of the lungs, partly from inflammation, but 
chiefly from congestion ; this is best relieved by counter-irritation to the 
chest and heat to the extremities. During the later stage the principal 
danger is from exhaustion; this forbids the use of all depressing meas- 
ures, and necessitates the most careful attention to the nutrition of 
the patient throughout the disease. All unnecessary medication is to In- 
avoided, particularly the use of expectorant mixtures, on account of tin- 
disturbance of the stomach. Opium is to be used very sparingly, and in 
most cases it should be withheld altogether. The cough is best relieved 
by inhalations of creosote, and the nervous symptoms by phenacetine or 
baths. For local use, the oiled-silk jacket is better than poultices. Coun- 
ter-irritation by mustard should be continued throughout the attack. 
when there is much bronchitis. Where antipyretics are required, cold ia 
safer and more efficient than the use of drugs. Of the cardiac Btimulants, 
alcohol and strychnia are most to be depended upon. Care Bhould 
be taken in all cases to maintain a good peripheral circulation. In sudden 
general collapse, the most valuable measurea are hoi mustard bathe, 
strychnia hypodermically, alcohol freely by the mouth, and the inhala- 
tion of oxygen. In protracted cases, and in those with delayed resolution, 
change of "air is more important than all ether means combined. 



514 



DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER V. 

DISEASES OF THE LUNGS.— {Continued.) 

LOBAR PNEUMONIA. 

Synonyms : Fibrinous pneumonia, croupous pneumonia, pneumonic fever. 

With our present knowledge, this may be best defined as an infectious 
disease, caused by the micrococcus lanceolatus (pneumococcus) and ac- 
companied by a local lesion in the lungs. While in most cases the gen- 
eral symptoms correspond with the extent and severity of the local lesion, 
they may be out of all proportion to each other. 

Etiology. — Age. — Lobar pneumonia may occur at any age. I have 
recently seen a case in an infant of three months which followed the typi- 
cal course. It may be seen even in the newly-born, but it is not until 
after the second year that it begins to be frequent. After the third year 
nearly all the cases of primary pneumonia are of this variety.* 

Of 160 personal cases, and 340 collected from various sources, the ages 
were as follows : 



Age. 


Cases. 


Per cent. 


During the first year 


76 
309 
104 

11 


15 


From the second to the sixth year 


62 


" " seventh to the eleventh year 

" " twelfth to the fourteenth year 


21 

2 






Totals 


500 


100 







The greatest susceptibility appears to be from the second to the sixth 
year, and during this period it is most frequent from the third to the fifth 
year. 

Sex. — Of my own cases, 60 per cent were males, and the same pro- 
portion was noted in 544 collected cases. This predominance of males 
has been everywhere observed, but is as yet unexplained. 

Season. — In my series of cases, the seasons were divided as follows : 





Cases. 


Per cent. 


In the three winter months 


48 

62 

6 

20 


35 


" " spring " 


46 


" " summer " 


4 


" " autumn " 


15 


Totals 




136 






100 



* For the relative frequency of broncho- and lobar pneumonia during infancy, see 
the table on p. 479. 



LOBAR PNEUMONIA. 



515 



Lobar pneumonia, in children therefore, as in adults, occurs most fre- 
quently during the spring months. April showed the largest number of 
any single month. 

Previous condition. — In my hospital cases, 82 per cent of the children 
were previously in good condition, and only 18 per cent were delicate, 
rachitic, or syphilitic. This observation has been borne out bv my ex- 
perience in private practice — viz., that as a rule lobar pneumonia affects 
children who were previously healthy. 

Previous disease. — Previous attacks of pneunfonia are observed in but 
a small proportion of cases. It was noted only five times in 160 cases. 
In the vast majority of cases lobar pneumonia is a primary disease, 
although it occasionally occurs as a complication of pertussis, measles, 
typhoid or scarlet fever, and even diphtheria — chiefly, however, in chil- 
dren over three years old. 

Epidemics of lobar pneumonia I have never witnessed, although 
on several occasions I have seen two children in a family attacked either 
simultaneously or in rapid succession. Exhaustion, fatigue, and exposure 
are to be ranked as associated exciting causes. 

In addition to other causes, there is required for the production of the 
disease the presence and growth of the pneumococcus. 

Lesions. — The seat of the disease. — In 950 cases in children under 
fourteen vears, this was as follows : 



Seat of Disease. 


Personal 
cases. 


Collected 
cases. 


Totals. 


Right lung, upper lobe only 

" " middle " " 


39 

26 
13 


137 

4 
142 

<il 


176 
12 


" " lower " " 


168 


" " more than one lobe 


77 


Totals, right lung 


86 


347 


433 


Left lung upper lobe onlv 


2r, 

49 

9 


68 

214 


98 


" " lower " " 




" " more than one lobe 


B 






Totals, left lung 


83 


311 






'3 
9 


i:J 
88 
60 


18 




11 




69 






Totals both lun^s 


12 


ill 









The right lung was thus affected in 45*5 percent; fche lefl Inng in 
41-5 per cent; both lunga in 13 per cent. In the order of frequency, the 

disease involves, first, the left base; second, the right apex; third, the 
right base; fourth, the left apex. The disease affects, as a rale, a rii 
lobe, and often only a circumscribed portion of :i i sharply 

at the interlobar fissure. 



516 DISEASES OF THE RESPIRATORY SYSTEM. 

Lobar pneumonia among children is so rarely fatal that the oppor- 
tunities for a study of the peculiarities of the lesion have been somewhat 
limited. I have myself made eleven autopsies, and have among my hos- 
pital records reports of nine others, making twenty cases in all. The 
anatomical changes resemble those seen in the adult lung. There is an 
exudation into the alveoli and smaller bronchi of fibrin, serum, leucocytes, 
and red blood-cells (Fig. 73). There is usually in addition an in- 
flammation of the mucous membrane of the larger brondhi and of the 
pleura. The frequency and severity of the pleurisy is a peculiarity of the 
lesion in children. 

In the first stage, that of congestion, the portion of lung involved is 
dark-coloured, heavy, and oedematous, and shows under the microscope a 
serous and cellular exudation into the air vesicles, with swelling of the 
epithelial cells lining the aWeoli. 

In the second stage, that of red hepatization, there is usually some ex- 
udation upon the pulmonary pleura, generally a thin layer of fibrin, giving 
it a dull, granular look. The lung itself is of a uniform dark-red colour. 
It is solid, and cuts like liver. It looks as if it had been inflated to its 
utmost extent and then injected with a material which had solidified. The 
consolidated area is sharply defined. Under the microscope the air vesi- 
cles are seen to be distended with an exudation which is chiefly fibrin, 
but with some leucocytes, red blood-cells, and desquamated epithelial cells. 
The cells are chiefly leucocytes, and are usually more abundant than in 
the pneumonia of adults. 

In the third stage, or gray hepatization, the lung is more moist, and 
the inflammatory products are partly decolourized. This change takes 
place irregularly throughout the lung, giving it a mottled appearance. 

The fourth stage, that of resolution, follows gray hepatization, and 
consists in the degeneration and liquefaction of the products of inflamma- 
tion, which are ultimately carried away by the lymphatics, or pushed out 
into the bronchi and removed by coughing. 

The duration of the stage of congestion is from a few hours to several 
days ; that of the stage of red hepatization from two days to two or three 
weeks. This is the condition in which the lung is most often seen at 
autopsy. The stage of gray hepatization is commonly shorter. Eesolu- 
tion usually begins when the temperature falls to normal, but occasionally 
it may be delayed for several days. It is generally complete in about 
a week. 

Variations in the lesions. — (1.) Instead of clearing up at the usual time, 
the lung may remain consolidated for several weeks, and then resolve. 
(2.) The stage of gray hepatization may be followed by a great exudation 
of pus cells, which may everywhere infiltrate the affected lung ; or these 
may be circumscribed so as to form a single large abscess or many small 
ones. (3.) There may be small areas of gangrene. All these conditions 



LOBAR PNEUMONIA. 51 7 

are very rare in children. Purulent infiltration and delayed resolution 
were not noted in any of my cases, and gangrene but once. (4.) There 
may be excessive pleurisy, or pleuro-pnenmonia. This was found in one 
half of my autopsies. These cases will be separately considered elsewhere. 

Lesions in other organs. — With pneumonia of the left side, if compli- 
cated by pleurisy, there may also be pericarditis. This was seen in two 
of my cases. The pericardial inflammation closely resembled that of the 
pleura. There was a very abundant exudation of fibrin and pus, coating 
both surfaces of the pericardium. Acute meningitis has been rarely 
observed. It was met with twice in my cases. The form of inflammation 
was an acute, purulent meningitis, with a very abundant exudation of 
greenish-yellow lymph, chiefly at the convexity. In one of my cases peri- 
tonitis was also seen as a compUcation of pleuro-pneumonia. As the 
pneumococcus is found in all these inflammations, they may be regarded 
as examples of a more generalized infection than usually occurs. In most 
of these the other processes are secondary to that in the lungs, but some- 
times they begin simultaneously with, or may even precede, the pulmo- 
nary lesion. 

The heart is generally found in diastole, with the cavities, especially 
those of the right side, distended with soft clots. There may be found 
ante-mortem thrombi, which may extend into the pulmonary artery or 
the aorta. 

Symptoms. — (1.) The typical course. — A child three or four years of age, 
after a few hours of slight indisposition, is suddenly taken with vomiting, 
followed by a rapid rise in temperature. He is dull and heavy, complains 
of headache and general weakness, refuses food, and is easily persuaded to 
remain in bed. He has the appearance of being quite ill, even after a few 
hours. Occasionally sharp pain in the side is complained of. The skin is 
dry; there are marked thirst, restlessness, and the other symptoms which 
accompany fever. The temperature is found to be 104° F., or even higher ; 
the respirations 40 to 50 a minute; the pulse full, strong, and L20 t<» L30. 
On the second day the patient is no better. The temperature remains 
high; the tongue is coated; the anorexia continues; the pain is more 
severe ; cough is present and may be quite frequent. 

After the second or third day the patient is usually more comfortable, 
and sleeps better, but may be disturbed by the cough. At times their is 
restlessness, and at night there may even be slight delirium. The respi- 
ration continues rapid and the temperature high. These general symp- 
toms show very little change until the sixth or seventh day, when, after a 
long sleep, which has been more natural than before, the patienl wakes, 
decidedly improved as to all his symptoms. There is less fever, and the 
temperature continues to fall rapidly until it touches the normal lin 
it may even go below this. As the fever subsides the pulse drop* 
100, and the respirations to 25 or 30 a minute. Theappetite soon returns, 



518 DISEASES OF THE RESPIRATORY SYSTEM. 

and convalescence is usually rapid. In a week the patient is out of bed, 
and in a month from the beginning of the illness he is out of doors ; but 
it may be another month before he can be considered to have entirely re- 
covered. This is the course seen in fully two thirds of all the cases of 
lobar pneumonia at this age. 

(2.) Pneumonia of short duration. — Instead of ruuning the usual 
course of from five to eight days, cases are seen in which the duration is 
only three or four days, although the physical signs indicate that the 
process in the lung passes through the usual stages. These are the cases 
of short pneumonia, and they differ from the ordinary type chiefly in their 
duration. They are always mild. 

(3.) Abortive pneumonia. — This form of the disease is rarely seen in 
hospitals, but it is not infrequent in private practice where the physician 
is summoned at the earliest signs of illness. The onset is precisely like 
that of ordinary pneumonia, and may even be as severe as the average 
case. The physical examination of the chest gives all the signs of the 
first stage of the disease, but on the second or third day the physician is 
greatly surprised to find that the temperature has fallen to normal, and 
that all the physical signs have disappeared. The process in such cases 
does not seem to go beyond the first stage of congestion ; there is no evi- 
dence of hepatization of the lung. The course is often such as to lead 
the physician to the opinion that he has made a mistake in his diagnosis. 
There seems, however, to be no doubt that these are cases of genuine 
pneumonia. D'Espine found the pneumococcus in the sputum of such 
a case. This type of pneumonia corresponds with abortive types of other 
infectious diseases so frequently met with in children. The temperature 
curve in such a case is shown in Fig. 95, page 521. The diagnosis of these 
cases is always attended with some uncertainty. There can be no doubt 
that very many of the unexplained high temperatures of brief duration 
which are seen in children are from this cause. Exactly why the disease 
terminates in this way is not known. It may be because the resistance 
of the patient is greater than usual, or the virulence of the pneumococcus 
is less. 

(4.) The prolonged course. — Although usually lasting about a week, it 
is not rare for pneumonia to continue ten, twelve, or even fifteen days. 
This prolonged course is often due to the fact that the disease spreads 
from one part of the lung to another, involving in succession two and 
sometimes three lobes ; but it may occur when the process is limited to 
a single lobe. A prolonged temperature should always suggest the pos- 
sibility of complications, usually pleurisy. Prolonged cases are generally 
severe. 

(5.) Cerebral pneumonia. — This term was first applied by Rilliet and 
Barthez to cases of pneumonia in which the cerebral symptoms predomi- 
nated. They will be considered under special symptoms. 



LOBAR PNEUMONIA. 519 

Onset. — Prodromal symptoms of more than a few hours' duration are 
quite rare. The onset of lobar pneumonia is almost invariably sudden, 
with well-marked symptoms — vomiting, diarrhoea, chill, or convulsions. 
Vomiting is altogether the most frequently seen. It was the mode of 
onset in about one half my cases. In summer particularly, there may be 
vomiting and diarrhoea. A distinct chill is rare in a child under five 
years of age, and is not very common even in older children. Convul- 
sions are not very infrequent, being seen in about five per cent of the 
cases. Their occurrence depends upon the suddenness of the invasion 
and the susceptibility of the patient. 

Cough. — This is present in most of the cases throughout the disease, 
but often is not marked for the first day or two. It is seldom a distress- 
ing symptom. A disposition to suppress the cough on account of pain is 
very frequently noticed. 

Expectoration. — This is rarely seen in childhood, and practically never 
under five years of age. Children of ten or twelve may have the same 
expectoration as adults — white and viscid, or brownish-red early in the 
disease, yellow and abundant toward its close. 

Pain. — Headache and general muscular pains in the back and extremi- 
ties are frequent during the invasion. The characteristic pain, however, 
is pleuritic. It is not necessarily felt in the region of the affected 1uh.lt, 
and often not in the chest at all. It is frequently referred to the loin, the 
epigastrium, or to any region to which the intercostal nerves are distrib- 
uted. In a recent case, in a boy of seven years, for the first twelve hours 
there was intense localized pain in the right iliac fossa, associated with 
such extreme tenderness as to lead to the suspicion that the case was one 
of appendicitis. The pain may last throughout the disease, and occasion- 
ally it is a most distressing symptom ; but usually it is only moderate, and 
rather more severe early than late in the disease. 

Prostration. — This is one of the characteristic features of pneumonia. 
The patient is generally willing to go to bed on the first day of the attack, 
and shows little desire to leave it while the disease continues. " Walking 
cases " are not common in children. 

Respiration. — This is always accelerated, and generally oui of propor- 
tion to the pulse. The normal ratio of the respiration t<> the pulse is one 
to four; in pneumonia, frequently one to two. The respiration is no( 
laboured and not quite pantinir, although this term is sometimes used 
to describe it. It is jerky. There is a short inspiration, then a momen- 
tary pause, followed by a quick expiration, which is accompanied by a short 
moan. This expiratory moan is very characteristic. The rapidity ot 
piration is usually in proportion to the amount of lung involved, hut it is 
also modified by the temperature, as the respiration Irop fron 

to 30 in the course of a few hours at the crisis. 

Pulse. — In the early part of the disease this is frequent, full, 



520 



DISEASES OF THE RESPIRATORY SYSTEM. 



strong, from 110 to 140 a minute. Later it may be weak, small, com- 
pressible, and sometimes irregular. It is relatively more rapid in the child 
than in the adult. The frequency of the pulse is of less importance than 
its character. 

Temperature. — The typical temperature curve of lobar pneumonia 
(Fig. 92) is characterized by an abrupt rise usually to 104° or 105° F., and 
by daily fluctuations generally within the limits of two or three degrees 



105° 
101° 
103° 
102° 
101° 
100° 
99° 


1 


2 


3 


i 


5 


6 


7 


8 




A 


ri 












/ 




{ \ 


A 












» 


|(l 


A 










V 






\ 


















1 


















^y 


98° 












L- 







Fig. 92. — Typical temperature curve of lobar pneumonia. 

History. — Male, three years old ; in fair condition ; sudden onset ; sisrns of consolidation — 
bronchial respiration and voice, and dulness — over left lower lobe behind, not distinct until 
the morning of the fifth day. On the seventh day the lung was resolving. 

until the crisis, at which time the temperature falls to normal, usually in 
the course of twenty-four hours. After this time it does not go above the 
normal line. Such a curve is seen in the majority of cases over three 
years of age. 

In cases under three years of age it is not uncommon for the tempera- 
ture to be of a more or less remittent type (Fig. 93). 



107° 


1 


2 


3 


4 


5 


6 


7 


l 9 


10 


11 


12 


13 


U 


15 


16 


17 


18 


19 


20 


105° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
























































A 


|\ 
























i 


\ 




k 


A 


\t 


\ 




f 


















\ 




J 




A 




/\ 


7 


\ 


|\ 




/ 


















i r 








' 


\ 


J 




I 




/ 


















V 












1 




V 








1 


















\ 




\ 


















































\ 
















98° 
97° 


























U 


y 


/" 




































V 




V 









Fig. 93. — Lobar pneumonia with remittent temperature. 

History. — Female, eighteen months old; in fair condition; sudden onset; repeated exami- 
nations of chest made, but no abnormal signs until the ninth day, when there were very rude 
respiration and slight dulness at the right apex, in front; on the twelfth day all the signs of 
consolidation at the same point, no rales ; four days after the crisis the lungs were clear. 



These wide fluctuations often lead to great difficulty in diagnosis, par- 
ticularly if the physical signs appear late, as they not infrequently do. It 
is possible that some of them are to be explained by mixed infection. 

The following chart (Fig. 94) illustrates three features which are 
often seen in pneumonia : (1) A temperature which early in the disease is 
steadily high and as the day of crisis approaches becomes remittent ; (2) 
a secondary rise after being normal for twenty-four hours, which was due 



LOBAR PNEUMONIA. 



521 



in this instance to an extension of the disease to a new part of the luno- ; 
(3) a fall to a point considerably below normal at the time of the crisis. 
In this case the temperature fell in the course of eighteen hours from 



lu7 c 


1 


2 


3 


i 


5 


6 | 7 J8 I 9 1 10 1 11 12 13 11 15 16 


IT IS 19 


•: 


ioe° 

105° 
104° 
103° 
102° 
101° 
100° 












i 


























A / 


h 
















l\ 




/M 




r 7 
















AM /\ 


\ 




r 




















t 




V 


\ \ 




1 


i 


. 




























■1 ) 


i 




t 




























\ r i 


1 




\ 




















MINI 




j: 












97° 
96° 
95° 
91° 










/ V 










































































u w 








1 1 V 



Fig. 94. — Lobar pneumonia with subnormal temperature after th 



History. — Female, nineteen months old; fairly healthy: sudden onset; symptoms typical 
but physical signs delayed ; consolidation in left mammary region on the eighth day; on the 
ninth in right lung middle lobe; on the eleventh day a pseudo-critical drop, followed after 
twenty-four hours of apyrexia by a further rise, which was accompanied by signs of extension 

of the disease in the right lung. Resolution rapid after crisis. 



105° to 95° F.-j and later still lower; it was two days before it finally re- 
mained at the normal point. A fall to 96*5° or 9?° F. at the time of crisis 
is not uncommon. 

In the foregoing cases the fever terminated by crisis. In Fig. 95 is 
shown one ending by lysis. This is a mode of termination much more 
frequent in young children than in those who are older. Thus, in ninety- 



105° 
104° 
103° 
102 ° 
101° 
100 : 


1 


i 3 


-> 


6 : 


S 9 1" 


11 12 


13 


14 15 


10 17 








A. 1 


A . k 










dz~ 


« 




\ 


V \A / 












/ 




V 


v 










^ 




' 


r 


u 








V 




i 






\ 


















\„ 








99 J 




L 


j 








* 






98= 


r 











Fig. 95.— Abortive pneumonia in left rang, followed by typical pneumonia in right Lunj 

minating by lysis. 

History.— Male, seventeen months old : healthy : sudden onset : on the second day d 
nated fine rales in both lungs behind, and over left lower very feeble respiration, bigh-p I 
—i.e.. some bronchitis, with congestion (?) of left base. On the third, fourth, and tifll 
general symptoms gone and signs nearly disappeared. On the sixth day all symptoi 
monia, and on the seventh distinct consolidation of right base, real of 
course typical ; resolution rapid and complete. 



three of my own cases, nearly all of which were under three yeai 
the fever ended by crisis in forty-nine, and by lysis in forty-fonr; while 
in five hundred and twenty-two collected cases, the majority of which 
were in older children, three hundred and ninety-six ended by crisis, and 

one hundred and twenty-six by lysis. 

40 



522 DISEASES OF THE RESPIRATORY SYSTEM. 

The following table shows the day of crisis in five hundred and sixty- 
seven cases of lobar pneumonia in children who recovered : 



Second day 3 cases 

Third "" 22 " 

Fourth " 43 " 

Fifth '• 88 " 

Sixth " 83 " 

Seventh " 132 " 

Eighth " 73 " 

Ninth " 55 " 

Tenth " 22 " 



The Day of Crisis. 

Eleventh day 18 cases. 

Twelfth " 7 " 

Thirteenth day 8 " 

Fourteenth " 7 " 

Fifteenth " 1 case. 

Eighteenth " 3 cases. 

Twenty-first day 1 case. 

Twenty-sixth " 1 " 

567 



Prom this table it will be seen that the most frequent critical day is 
the seventh, and that in 66 per cent of the cases it was from the fifth to 
the eighth day. The causes of a post-critical rise in the temperature are 
chiefly two — extension of the disease to a new area, or the development 
of pleurisy, which is apt to be purulent. Less frequently it is due to 
meningitis, pericarditis, gastro-enteritis, or malaria. In fatal cases the 
temperature is generally high until the end. In general, it may be said 
that the temperature is considerably higher in children than in adults ; 
in the majority of cases it reaches 105° F., the usual range being from 
102° to 105° F. In fifteen of one hundred and thirty-seven cases, or 11 
per cent, it reached 106° F. or over. 

Gastro-enteric symptoms. — These are more common in infants than in 
older children. At the onset there is frequently vomiting, sometimes 
also diarrhoea. A continuance of the vomiting is rare, and is generally 
due to improper feeding or medication. It may be a very serious com- 
plication. Diarrhoea is also rare, except at the onset and in summer cases. 
It is sometimes seen at the time of crisis. Throughout the disease there 
are anorexia, coated tongue, and the usual symptoms of high fever. 

Nervous symptoms. — Cerebral symptoms are frequent and very often 
misleading. In seven of my cases the pneumonia was ushered in by convul- 
sions. These differ in no respect from convulsions from other causes, and 
may be repeated two or three times in the course of the first twenty-four 
hours. They are sometimes followed by drowsiness or stupor, sometimes 
by active delirium. Cerebral symptoms may predominate for several days. 
There may be opisthotonus, dilated or contracted pupils, irregular pulse, 
retracted abdomen, and, in fact, almost every symptom of meningitis. 
Occasionally the decubitus en chien de fusil, or gun-hammer position, is 
assumed. These are often described as cases of cerebral pneumonia, and 
in many of them pneumonia is not suspected until the fourth or fifth day 
of the disease, sometimes not until the crisis occurs, when the rapid dis- 
appearance of all these nervous symptoms indicates their origin. Early 



LOBAR PNEUMONIA. 523 

convulsions are not generally followed by an especially severe type of the 
disease, only one of seven cases beginning in this way proving fatal. On 
the other hand, late convulsions are usually fatal. In two of the three 
cases in which I have noted them, the convulsions ushered in an attack of 
meningitis. 

Delirium is much more frequent than convulsions, and is seen in 
nearly one fourth of the cases. Generally it is slight, and noticed only at 
night or when the temperature is very high. It is usually mild, but may 
be low and muttering, like that of typhoid, or wild and active, like that of 
cerebro-spinal meningitis. It is most pronounced at the height of the 
disease. Other nervous symptoms belonging to the typhoid state, such 
as incontinence of urine or faeces, muscular twitchings, and tremor of the 
tongue on protrusion, are occasionally seen, but only in the worst forms 
of the disease. 

There is no relation between the seat of the disease in the lungs and the 
occurrence of cerebral symptoms. They are more frequent in children 
under five years than in those who are older, and depend upon the sudden- 
ness of the invasion, the intensity of the infection, and the susceptibility 
of the child. Late in the disease they may indicate exhaustion, toxaemia, 
or complicating meningitis. They are frequently associated with very 
high temperature and extensive disease.* The usual nervous symptoms — 
restlessness, headache, sleeplessness, etc. — are nearly always proportionate 
to the height of the temperature. 

Urine. — Throughout the febrile period of the disease the urine is 
scanty, high-coloured, with a high specific gravity, and usually loaded 
with urates. In a small number of cases a trace of albumin may be 
found, and occasionally a few hyaline casts. Evidences of serious renal 
disease I have seldom found in lobar pneumonia, and in the experience of 
all observers it is extremely rare in early life. 

Shin. — The face, in pneumonia, is usually flushed, sometimes on both 
sides and sometimes only on one; in other cases it is pale, but nol in- 
dicative of pain. Cyanosis is rare except toward the close of the die 
and is usually a sign of respiratory failure. Eerpes of the lips or fa 
quite frequent. 

Physical Signs. — The earliesl signs in pneumonia are due to the acute 
congestion of the affected lung or lobe, in consequence of which less air 
enters this portion and more air the rest of the lungs. Percussion 
diminished resonance or slight dulness over the affected area, and 1 
gerated resonance over the remainder of this lung and <>\rv the opposite 
lung. Auscultation over the affected lobe gives feeble respiratory murmur, 
rather high in pitch ; sometimes there may be absence of all breath-sounds 



* For a fuller discussion of the cerebral Bymptoma of pneumonia, see a paper by 

the author, in the New York Medical Record, April 7. 1888. 



524 DISEASES OP THE RESPIRATORY SYSTEM. 

so complete as to suggest fluid. The normal respiratory murmur over the 
healthy portions of the lungs is intensified. In children this exaggerated 
breathing is not infrequently mistaken for bronchial breathing, and the 
physician may be led into the error of locating the pneumonia upon the 
wrong side. Exaggerated breathing does not differ from normal breathing 
except in intensity, and is heard only on inspiration. Bronchial breathing 
is higher in pitch, and is heard with nearly equal intensity both on ex- 
piration and inspiration. If the chest is frequently auscultated, crepitant 
rales (Figs. 96 and 97) may usually be heard at some period at the end of 
full inspiration, but often they are but for a few hours and they may be 
missed altogether. 

In the second stage, that of consolidation (Fig. 98), no air enters the 
affected part of the lung. Upon palpation there is found here exaggerated 
vocal fremitus, and on percussion there is marked dulness, but very rarely 
flatness. Over the rest of this lung there is exaggerated, sometimes even 
tympanitic, resonance ; this is especially frequent at the apex of the lung 
in front, when there is consolidation at the base behind. Under these 
conditions cracked-pot resonance may sometimes be obtained. Over the 
healthy lung there is exaggerated resonance. On auscultation over the 
consolidated portion there are bronchial breathing and bronchial voice, 
the area over which they are heard being sharply limited. Kales are usu- 
ally absent, but there may be pleuritic friction sounds. 

In the stage of resolution there is a gradual disappearance of the 
signs of consolidation. The pure bronchial is replaced by broncho-vesic- 
ular breathing, the vesicular element gradually predominating. Moist 
rales of all varieties are heard. Usually the most persistent signs are 
slight dulness or diminished resonance, with a respiratory murmur which 
is feebler than normal and a little higher in pitch ; sometimes there are 
also dry friction sounds. These signs may persist for two or three weeks. 

Exceptional physical signs. — While in the majority of cases the signs 
of consolidation are distinct on or before the fourth day, in not a few they 
may be delayed much longer. Of eighty-two cases in which the day was 
noted on which consolidation was found, it was not until the fifth day or 
later in one fourth the number. In six of them, although carefully and 
repeatedly examined, no consolidation was found until the seventh day or 
later and in one case not until the twelfth day. It has been customary 
to look upon these cases of delayed or concealed physical signs as cases 
of central pneumonia. That pneumonia may exist in the centre of a 
lung for a number of days is, to my mind, extremely improbable. At 
autopsy, superficial pneumonia I have very frequently seen, but central 
pneumonia never. There are two regions in which pneumonia may exist 
and yet not be accessible by our means of physical examination, viz., at 
the apex of the lung in the part covered by the shoulder, and along the 
posterior border of the lung where it lies against the vertebras. In either 



PHYSICAL SIGXS OF LOBAR PXEUMOXIA. 




Fig. 96. — First stage. Congestion of left lower Fig. 97. — In the centre of the area, a small spot of 
lobe, with crepitant rales. Feeble breathing pure bronchial breathing and voice ; Burround- 

of a rude character, with slight dulness. ing this an occasional crepitant nMe, with 

broncho-vesicuiar breathing and slight ful- 
ness. 



Fig 98 —Second sta^e. Complete consolidation of left lower lobe. Pure bronohial bn 

chial voice; marked dulness; increased vocal fremitus, and at the lower part a few friction und*. 



Notk.— During resolution the sign- take the inverse order : those ot I 
those of Vig. 97, and these in tun, to those of Fig, 06. In addition, many ma) 

be heard. 

536 



526 DISEASES OF THE RESPIRATORY SYSTEM. 

of these situations pneumonia may be present without our being able to 
find it. It is quite common in cases with late physical signs that the first 
distinctive evidences of disease are found high in the axilla, or beneath 
the clavicle in front, and these regions should be closely watched in doubt- 
ful cases. Sometimes the delay is best explained by assuming that con- 
stitutional symptoms due to the pneumococcus infection, may be pres- 
ent for several days before the development of the local lesion in the 
lung. 

Complications. — The occurrence of dry pleurisy over the consolidated 
portion of the lung is so constant that it can hardly be considered a com- 
plication. A slight serous exudation of two or three ounces is not un- 
common, but more than this is very rare in young children. In the most 
severe cases of pleurisy there is an excessive exudation of fibrin and pus. 
This occurred in eight per cent of my cases. This variety is known clin- 
ically as pleuro-pneumonia, and will be considered separately. Pericarditis 
is rare ; it was seen in only two of my cases ; in both it was associated with 
pleuro-pneumonia of the left side, the exudation resembling that found 
on the pleura. It rarely gives rise to any new symptoms. Meningitis was 
seen twice, once with pleuro-pneumonia. It is nearly always ushered in 
by repeated attacks of vomiting or convulsions. Its course is short and 
progressive. Peritonitis was seen once, also associated with pleuro-pneu- 
monia. Occasionally there is gastro-enteritis. 

Course and Termination. — In the great majority of cases lobar pneu- 
monia terminates either in perfect recovery or in death. When ending 
in recovery, resolution commonly begins immediately upon the cessation 
of the fever, and is complete in about a week. Delayed resolution is very 
rare ; chronic pneumonia and tuberculosis are also extremely infrequent 
as sequelae, but empyema is quite common. Its symptoms sometimes de- 
velop immediately after the pneumonia, the temperature continuing high ; 
or there may be an interval of a few days before the development of the 
pleural symptoms. Some pleuritic adhesions probably remain in every 
case in which there has been much dry pleurisy, and when severe and 
extensive, these may be the cause of subsequent symptoms, like any other 
dry pleurisy. 

Death from uncomplicated pneumonia may be due to exhaustion, or 
to heart failure, with or without failure of the respiration. The signs of 
heart failure sometimes develop quite rapidly in cases which are apparently 
doing well. The first symptoms are : coldness of the hands and feet, then 
of the legs and arms ; a rapid, compressible, and sometimes irregular 
pulse ; muscular weakness and pallor, but usually no cyanosis. The symp- 
toms of respiratory failure are : very rapid superficial respirations, some- 
times 100 a minute ; blueness of the lips and finger nails ; often a leaden 
hue of the whole body ; there are loud tracheal rales, and recession of 
all the soft parts of the chest on inspiration. 



LOBAR PNEUMONIA. 



527 



Death may result early in the disease, where the pneumonia has spread 
rapidly, involving both lungs. The earliest deaths I have seen were on 
the fourth day, and were due to a failure of the heart and respiration. 
In most of the uncomplicated fatal cases, death results from heart failure 
at about the time of the crisis. In the complicated cases death usually 
occurs in the second week. I once knew fatal meningitis to develop at 
the end of the fourth week. 

Diagnosis. — The most characteristic differences between broncho- and 
lobar pneumonia are shown in the following table : 



BBONCHO-PNEUMONIA. 

1. More than half the cases secondary. 

2. Under three, chiefly under two years. 

3. Occurs more frequently in delicate 
and debilitated children. 

4. Bacteria — in primary cases, usually 
the pneumococcus ; in secondary cases, 
chiefly the streptococcus, but usually mixed 
infection. 

5. Products of inflammation chiefly cel- 
lular ; process often diffuse. 

6. Onset often gradual, sometimes in- 
sidious, especially when secondary. 

7. No typical course ; fever often lasts 
three or four weeks ; rarely terminates by 
crisis. 

8. Involves both lungs as a rule, most 
frequently lower lobes posteriorly. 

9. Signs of bronchitis mingled with 
those of consolidation ; rales in other parts 
of the same lung, or in the opposite lung, 
throughout the disease. 

10. Consolidation later— fourth to sev- 
enth day : there may be none ; apt to be 
incomplete; shades off gradually. 

11. Resolution slow, one week to two 
months; often incomplete; strong tend- 
ency to become chronic. 

12. Relapses and second attacks fre- 
quent. 

13. Sequehe: Empyema, chronic inter- 
stitial pneumonia, sometimes tubercu- 
losis. 

14. Prognosis always serious from the 
age and the circumstances under which 
disease occurs. 

15. Hospital mortality 50 per cent of 
primary cases, 65 per cent of all ca 



LOBAR PNEUMONIA. 

1. Almost always primary. 

2. Most common between three and 
eight years. 

3. More often in those previously 
healthy. 

4. The pneumococcus. 



5. Chiefly fibrin ; process circumscribed. 

6. Onset sudden, with well-marked 
symptoms. 

7. Typical course; crisis usually from 
fifth to eighth day. 

8. Usually one lobe or a part of a Lobe : 
left base most frequently, right apex next. 

9. Rales only early, and during 
lution; frequently no signs in opposite 

lung. 

10. Consolidation earlier; second or 
third day. Consnlidat ion complete | 
usually sharply defined. 

11. Resolution rapid, usually complete 
within a week. 

12. Both are rare. 

18. No sequelae except empyema, 



1 I. Prognosis good ; rarely fatal ex- 
cept from complication — empyema, men- 
iugit is. pericardii is. 

L5. .Mortality 4 per cent of all • 



528 DISEASES OF THE RESPIRATORY SYSTEM. 

In the majority of cases the symptoms are plain and the physical 
signs so typical that it is difficult to overlook pneumonia if any degree 
of care is used in the examination of the patient. The characteristic 
features are the sudden onset, with vomiting, convulsions, or chill ; pros- 
tration ; rapid respiration, with the expiratory moan ; a temperature of 
102° to 105° F. ; cough and thoracic pain ; and the physical signs of a 
rapidly developing, circumscribed consolidation in one lobe or a portion of 
a lobe.' The difficulties in diagnosis are due to the great variation that is 
seen in the general symptoms, and to the late appearance of the physical 
signs. The error usually made is to mistake pneumonia for some other 
disease, rather than to mistake some other disease for pneumonia. On 
account of its frequency in children, pneumonia should always be ex- 
cluded before accepting any other explanation of a continuously high 
temperature. It is surprising to find how often obscure and indefinite 
symptoms accompanied by high fever, are due to pneumonia. The rule 
should be followed, in all cases of acute illness, of making a thorough 
examination of the chest daily until the diagnosis is clear. If to high 
temperature rapid respiration is added, one should always suspect the 
lungs, no matter what the other symptoms may be. It not infrequently 
happens that the general symptoms are quite characteristic and yet the 
physical signs appear late. In such cases pneumonia should always be 
looked for high in the axilla or just beneath the clavicle, since it is par- 
ticularly in the cases of apex pneumonia that this obscurity is likely to 
exist. If frequent and thorough examinations of the chest are made, very 
few cases will be overlooked. 

In their onset, scarlet fever, tonsillitis, and gastro-enteritis may all re- 
semble pneumonia. Scarlet fever is recognised by the sore throat and the 
characteristic eruption on the second day ; tonsillitis, by the local symp- 
toms. Pneumonia is distinguished from gastro-enteritis, by the fact that 
the temperature and prostration are out of all proportion to the intestinal 
symptoms, and continue even after these symptoms have subsided. It is 
most likely to be mistaken for gastro-enteritis in summer, and in infancy, 
when it often begins with vomiting and diarrhoea. Malaria is distinguished 
from lobar pneumonia by the points mentioned in the diagnosis of broncho- 
pneumonia (page 507). From all other general diseases, pneumonia is to 
be differentiated by the physical signs. 

Pneumonia with marked cerebral symptoms sometimes resembles cere- 
brospinal meningitis. In both we may have the abrupt onset, convul- 
sions, delirium or stupor, opisthotonus, and prostration. In pneumonia 
the temperature is usually higher than in meningitis ; the pulse is never 
slow and intermittent ; the respiration is rapid, instead of slow and irregu- 
lar ; and the stupor is usually less profound ; and there are no localized 
paralyses. In meningitis there is a steady increase in the severity of the 
nervous symptoms for the first three or four days; in pneumonia they 



LOBAR PNEUMONIA. 529 

are as a rule most marked during the first twenty-four or forty-eight 
hours, and then gradually diminish, always subsiding completely at the 
crisis. While most of the individual symptoms belonging to meningitis 
may be present, they are usually less severe and less persistent in pneu- 
monia. 

The question sometimes arises, in a case of pneumonia, whether the 
cerebral symptoms are functional, or whether meningitis also exists. If 
the nervous symptoms are present from the beginning, there is probably 
no meningitis. If they develop suddenly during the course or toward the 
close of the disease, meningitis should be suspected. 

Lobar pneumonia is to be differentiated from a pleuritic effusion. 
The most common mistake w r hich I have seen made is to confound empy- 
ema with unresolved pneumonia. The latter is very infrequent, so that 
the probabilities are always strongly in favour of the diagnosis of empy- 
ema. In pneumonia rarely, if ever, is the whole lung affected. There 
are increased vocal fremitus, dulness, bronchial voice and breathing, and 
occasionally rales or friction sounds. In empyema the whole lung is 
often affected, there are displacement of the heart, flatness on percus- 
sion, diminished or absent vocal fremitus, and although bronchial voice 
and breathing are present, they are usually distant and feeble. There 
are no rales or friction sounds. In doubtful cases an exploratory punc- 
ture should always be made. Serous effusions are rare, but are differen- 
tiated by the same signs as empyema. 

Prognosis. — There is probably no disease in which the patient appears 
so ill, and where there is really so little danger to life, as in lobar pneu- 
monia in a child over three years old. Of 1,295 collected cases, chiefly 
from hospital practice, there were but 39 deaths, a mortality of three per 
cent. In 187 cases of my own there were 21 deaths, a mortality of eleven 
per cent. Only one of the fatal cases was over two years old. The dif- 
ference between the mortality among my cases and the general mortality 
given, is due to the fact that a large proportion of the first group were 
observed in children under two years, while of the collected cases the 
vast majority were in older children. Combining the above figures, we 
have a total of 1,482 cases with GO deaths, a mortality of four percent 
In nearly all my cases death was due either to complications or t<> ?ery 
extensive disease, as when both lungs were involved, or aearly the whole 
of one lung. In only one case was an uncomplicated pneumonia of a 
single lobe fatal. 

The prognosis depends upon the age of the patient, the presence or 
absence of complications, and the extent of the disease. These factoi 
to be taken into consideration rather than any special Bymptoma Early 
convulsions do not materially affeel the prognosis. Of Beven such 
only one was fatal. Late convulsions are always very unfavourable, indi- 
cating either exhaustion, toxa-niia. or the development of nienin 
41 



530 DISEASES OF THE RESPIRATORY SYSTEM. 

The development of vomiting or diarrhoea late in the disease is also 
unfavourable, especially in infants. 

A temperature range between 102° and 105° F. is the rule, and 
within these limits the fever does not affect the prognosis. Even 
very high temperature does not increase the danger from the disease 
as much as would be expected. Of fifteen cases in which the tempera- 
ture touched 106° F. or over, all but three recovered; while of six 
cases in which it was 106-5° or over, only one died. The highest re- 
corded temperature in my cases — 107-5° F. — was in a patient who recov- 
ered. A transient rise, even though the temperature may go very high, 
is not often serious. Much more serious is a fever which remains 
steadily above 105° F., as in most cases this accompanies either very ex- 
tensive disease or pleuro-pneumonia. The continuance of the fever after 
the tenth day is a bad symptom, for, although the crisis may be post- 
poned until the twelfth day and occur normally, such a prolonged tem- 
perature is apt to be an indication of a new focus of disease or the devel- 
opment of complications. 

It is an unfavourable sign for resolution not to begin as soon as the 
temperature becomes normal. There should then be apprehended a re- 
lapse, the development of empyema, or of some other complication. 

Treatment.— In the treatment of lobar pneumonia in children, several 
cardinal facts are to be kept in mind. It is a self -limited disease, having 
a strong tendency to recovery in the great majority of cases regardless 
of the treatment adopted. The fatal cases are almost always in children 
under three years of age ; the rare deaths in older ones are usually due 
to complications. I believe that there is no means of treatment by which 
we can abort pneumonia or shorten its course. It follows, therefore, that 
the indications are, so far as possible, to make the patient comfortable 
during his illness, to prevent complications, and to treat the individual 
symptoms as they arise. 

In perhaps the majority of cases, hygienic treatment is all that is 
required. The patient should be kept in bed, no matter how mild the 
attack ; he should be lightly covered, kept as quiet as possible, and 
allowed plenty of fresh air in the room. Food should be given at regu- 
lar intervals, never oftener than every two hours, and usually only 
every four hours. It should not be forced when the patient is suffering 
only from thirst. These measures, careful nursing, an occasional dose 
of phenacetine when the patient is very restless, fretful, or sleepless, 
and cold sponging when the temperature makes him uncomfortable, are 
usually all that is necessary, except to keep a sharp lookout for compli- 
cations. 

Special symptoms may require treatment. The nervous symptoms are, 
in most cases, better controlled by phenacetine than by opiates. Often a 
single dose in twenty-four hours is enough. Sometimes sponging with 



PLEURO-PXEUMOXIA. 53 1 

tepid water is better than drugs. Severe nervous symptoms, such as delir- 
ium, stupor, great restlessness with impending convulsions, when associ- 
ated with high temperature, call for ice to the head, cold sponging, or the 
cold pack or bath. Pain, if moderate, may be relieved by counter-irrita- 
tion by a mustard paste or by a hot poultice ; if severe, morphine must 
be used in addition. The cough is rarely severe enough to require treat- 
ment. When it is so severe as to prevent sleep, small doses of Dover's 
powder or codeia should be given. Antipyretic measures are not neces- 
sarily called for if the temperature is high. This not infrequently con- 
tinues for a few hours while the patient may be quiet and appear perfectlv 
comfortable. Under such conditions the temperature should be closely 
watched, but not necessarily interfered with unless other symptoms de- 
velop. The nervous s} T mptoms are a better guide than the thermometer 
to the use of antipyretics. When they exist, even with a moderate ele- 
vation of temperature, interference is indicated. Cold I believe to be 
the safest and most certain antipyretic we possess. It may be given as 
a cold sponge bath or the cold pack (pages 47, 48). There is no objection 
to the bath except the prejudice of the laity. "While cold is applied to 
the trunk the extremities should be closely watched, and heat applied if 
necessary. The duration of the pack or bath, and the frequency of their 
use, will depend upon the individual case. Stimulants are not required in 
the majority of cases. They are called for when the pulse is weak, com- 
pressible, and rapid, when the face is pale and the extremities are cold. 
The same stimulants are to be employed, and in the same way, as in 
broncho-pneumonia (page 510). Cardiac stimulants are usually require] 
in larger quantity at the time of and just after the crisis. Respiratory 
stimulants are indicated as in broncho-pneumonia. 

PLEURO-PN B l' M ( >XI A. 

Under this term are included cases of pneumonia with an ex< ■• 
amount of pleurisy, the two processes uniting to produce a single clinical 
type of disease. 

In nearly all cases of lobar pneumonia there is a certain amount of in- 
flammation of the pulmonary pleura, and also in those cases of broncho- 
pneumonia which are accompanied by any marked degree of consolidation. 
In both of these the pleurisy is usually co-extensive with the consolidation. 
But in certain cases, in both forms of pneumonia, the amount of pleurisy 
is excessive, and this so modifies the symptoms and course <»f the dia 
as to require for them a separate consideration. In some it appears that 
the inflammatory process begins almost simultaneously in the lung and in 
the pleura; while in others the pleurisy follows the pneumonia. These 
cases are, I believe, almost invariably din; to the pneumococcus, although 
in some there is a mixed infection. 

In 398 hospital cases of pneumonia tl 



532 DISEASES OF THE RESPIRATORY SYSTEM. 

which could be classed as pleuro-pneumonia, the diagnosis being con- 
firmed either by autopsy or operation. Of 190 fatal cases, 12*5 per cent 
were pleuro-pneumonia. Most of these hospital patients were under three 
years of age, and the disease is, I think, more frequent at this period than 
in older children. 

Lesions. — Of these 27 cases, 17 were classed as broncho-pneumonia and 
10 as lobar pneumonia. The left lung was more frequently affected than 
the right in the proportion of three to two. In most of the cases the 
pleura covering the entire lung was involved, even though the pneumonia 
affected but a single lobe, or only a part of a lobe. In nearly half the cases 
both lungs were involved, but one to a very much less extent than the 
other. In a small number of cases the pleurisy was limited to the pos- 
terior surface of the lung, stopping at the axillary line. 

In pleuro-pneumonia both the visceral and the parietal pleura are 
coated with a layer of yellowish-green fibrin, in thick, shaggy masses, by 
which the lung is adherent to the chest wall, the diaphragm, and the 
pericardium (Plate XIII). The exudation varies between one eighth 
and one half an inch in thickness. It can often be stripped from the 
lung or scraped from the chest wall by the handful. In its meshes small 
pockets may form, which contain only a few drops, or sometimes a 
drachm of pus, or less frequently serum. This is the condition in which 
the lung is usually found where death has occurred at the height of the 
disease. If the process has lasted longer, larger collections of pus may be 
found. The lung itself shows the usual changes of pneumonia, and if 
there has been any considerable accumulation of fluid, there are in addi- 
tion the evidences of compression. 

With pleuro-pneumonia of the left side, the pericardium is occa- 
sionally involved. This was seen in two of my cases, the lesions closely 
resembling those of the pleura. In two cases there was also meningitis, 
and in one peritonitis, the exudation in all cases having the same charac- 
teristics. 

An inflammation of the intensity described is very often fatal in the 
acute stage, if the patient is a child under two years old. Occasionally 
at this age, and very frequently in older children, we see the later stages 
of the process. The most frequent course is for more and more pus to be 
poured out from the inflamed pleura until the chest is filled, the case 
becoming thus one of empyema. Sometimes the fluid is serous instead of 
purulent, but this is very rare in infancy. Under other circumstances the 
exudation is partly absorbed, but the greater part becomes organized so as 
to form a thick jacket of fibrous tissue which binds the lobe or lung to 
the chest wall, and interferes seriously with its subsequent full expansion. 
Chronic interstitial pneumonia may follow. 

Symptoms. — There is little which distinguishes a case of pleuro-pneu- 
monia except the severity of all the constitutional symptoms ; the tern- 



PLATE XIII. 




= 1 

Si 

- x 



_ _z 
c d 









^ -. 









- c: 
5 ' -^ 



H 




, 






• 






PLEURO-PNEUMONIA. 533 

perature is often higher, the prostration greater, and the patient in every 
way impresses one as being more seriously ill than with ordinary pneu- 
monia. Sometimes the thoracic pain is more severe and more constant 
than is usual in pneumonia. The diagnosis, however, is to be made by 
the physical signs. 

In the early stage the pleuritic friction sounds are unusually promi- 
nent; after two or three days the signs of consolidation come out clearly 
in most cases, but still accompanied by loud friction sounds. After the 
fibrinous exudation is very abundant, the signs are often obscure and con- 
fusing, and there may be at no time well-defined signs of consolidation. 
There is usually a mingling of the signs of consolidation with those of 
effusion. There is marked dulness, and sometimes flatness. The vocal 
fremitus is apt to be diminished, and it may be absent. Bronchial voice 
and breathing are heard, but they are not distinct as in consolidation ; 
they are, however, feeble and distant, as over fluid. There are usually 
coarse, moist, crackling pleuritic sounds, but these may be absent. The 
signs may be found over one entire lung, or they may be limited to 
the posterior region, and even to a single lobe. They resemble those 
present over fluid, with one exception — viz., the heart is not displaced. 
If an exploratory puncture is made, nothing is found ; occasionally the 
exploring needle happens to strike one of the small pockets of pus 
in the meshes of the fibrin, and a few drops of clear pus are withdrawn. 
If an incision is made under the supposition that the case is one of em- 
pyema, no more pus may be found, the surgeon coming upon the pul- 
monary adhesions as soon as the chest is opened. There is scarcely any 
condition in the chest giving signs more puzzling than those just enu- 
merated. They are, however, easily explained by the pathological con- 
ditions. 

Prognosis. — The prognosis in pleuro-pncumonia is much worse than 
in simple pneumonia. In infants the outlook is very bad, the majority of 
cases dying during the acute stage, usually in the second week. Very 
young children may be overwhelmed with the extent and the intensity of 
the inflammation, and die in four or five days. In children over two years 
old the most frequent result is for the case to go on to empyema, which 
with proper treatment usually terminates in recovery. Where there is 
organization of the fibrin with the production of extensive adhesions, the 
ultimate result is often not so favourable as when empyema develops. 
Convalescence is usually slow, and the patients are liable to exacerbations of 
pleurisy; they may suffer for years from the partial crippling of one lung. 

Diagnosis.— This is to be made only by the physical signs, A differ- 
ential diagnosis from fluid in the chesl can in some cases be made only 
by an exploratory puncture. 

Treatment— Cases of pleuro-pneumonia require no special treatment 
In general they are to be managed like the, ordinary cases of pneumi 



534 DISEASES OF THE RESPIRATORY SYSTEM. 

of the severe type. In some, the excessive pain may call for more active 
counter-irritation and a freer use of opium than in other forms of pneu- 
monia, and the greater prostration may require that stimulants be given 
earlier and in larger quantities. 

HYPOSTATIC PNEUMONIA. 

This can not often be recognised clinically, but it is very frequently seen 
upon the post-mortem table. It is present in some degree in almost every 
case where an infant has died of chronic disease. It is particularly fre- 
quent in those who have died of marasmus. It is sometimes described 
as " strip pneumonia," on account of its position. It invariably occupies 
a strip along the posterior border of both lungs, and usually of both the 
upper and lower lobes. This is from one to two inches wide, of a uniform 
dark-red colour, and is sharply outlined. The pleura is not involved, and 
the remainder of the lung may be normal, congested, or slightly emphy- 
sematous. On section, it is seen that the pneumonic area is quite super- 
ficial, rarely involving the lung to a greater depth than half an inch. Un- 
der the microscope there is found a distention of the small blood-vessels in 
the affected area, and the air vesicles are filled with many red blood-glob- 
ules, epithelial cells, and a few leucocytes. Between the areas of consoli- 
dation are groups of air vesicles which are normal, congested, or collapsed. 
It is a lobular rather than a broncho-pneumonia. The lesions in this 
form of pneumonia are probably the result of venous stasis, owing to the 
child's recumbent position. 

At autopsy the condition may be confounded with atelectasis; this, 
however, is almost invariably more marked in the interior of the lung, 
while pneumonia is always more marked upon the surface. The two con- 
ditions are sometimes associated. Little significance is to be attached 
to the finding of hypostatic pneumonia at autopsy, and it alone should 
never be regarded as a sufficient cause of death, although it is perhaps the 
only lesion present. During life it may give rise to fine moist rales, which 
are heard along the spine, usually upon both sides ; but there is neither 
dulness nor bronchial breathing. 

The treatment is that of the primary disease. 

CHRONIC BRONCHO-PNEUMONIA— CHRONIC INTERSTITIAL 
PNEUMONIA— BRONCHIECTASIS. 

This is an inflammation of the connective-tissue framework of the 
lung, involving the stroma, the alveolar septa, the walls of the bronchi, 
and the pleura. It is usually accompanied by cylindrical dilatation of the 
bronchi — bronchiectasis. 

Etiology. — In children, as in adults, this process is most frequently 
associated with pulmonary tuberculosis; but in early life it is not an in- 



PLATE XIV. 




Chronic Broncho-Pneumonia. 

In the greater part of the specimen the disease is limited to the vicinity of the 
small bronchi, AAA, each of which is surrounded by a zone of new connective 
tissue, the result of the inflammatory process, the intervening lung tissue, B B, being 
normal. In the lower left-hand portion, the disease is more diffuse ; the air vesicles, 
C, between the areas of new connective tissue are greatly compressed, and in some 
places entirely obliterated. (After Delafield.) 



CHRONIC BRONCHO-PNEUMONIA. 535 

frequent condition apart from tuberculosis. The non-tubercular .cases, as 
a rule, are preceded by an attack of acute broncho-pneumonia, sometimes 
by several such attacks, separated by longer or shorter intervals. 

Lesions. — The part of the lung affected may be an entire lobe, but 
usually it is a portion of one lobe, or there are areas in more than one 
lobe. There are dense connective- tissue adhesions binding the diseased 
part to the chest wall, to the diaphragm and to the pericardium, often 
so firmly that the lung is torn on removal. The affected lung is smaller 
than in health ; it is hard, tough, and fibrous. Surrounding the fibrous 
portions are emphysematous areas. On section, the process is seen to 
be somewhat irregularly distributed through the lung, the lesion being 
usually most marked in the vicinity of the smaller bronchi, and some- 
times seen only there, the intervening lung being nearly normal (Plate 
XIV). In some portions, where the process is most advanced, almost 
all trace of lung tissue has disappeared, the part resembling a solid fibrous 
tumour, through which run the bronchial tubes, usually much dilated. 
In places this dilatation may be sufficient to form cavities of consid- 
erable size. The bronchial glands are often enlarged to the size of a 
hazelnut, and they may be tubercular. 

Upon examination with the microscope, the pleura is found greatly 
thickened, with bands of new fibrous tissue passing from it into the 
lung. The walls of the small bronchi are generally thickened, but in 
some places they have undergone cylindrical dilatation, and are filled 
with pus. The walls of the alveoli are greatly thickened from the pro- 
liferation of the connective-tissue elements, and the alveoli are filled 
with organized inflammatory products, so that they are nearly or quite 
obliterated. The stroma is greatly increased in amount throughout the 
affected lung. 

Symptoms. — In most of the cases there is a history of an attack of 
acute broncho-pneumonia, from which the child made a slow convales- 
cence, remaining pale, anaemic, and sometimes wasted for several months. 
Improvement then takes place in the general symptoms the appetite and 
strength return, and in many cases the lost weight is nearly or quite re- 
gained. However, neither the pulmonary symptoms nor the physical Bigna 
entirely disappear. There remains a dry, hard cough, which at timi 
severe. Pains in the chest are occasionally complained of, and perhaps 
shortness of breath on exertion is noticed. Examination Bhowa a per- 
sistence of the dulness on percussion, with a rude or broncho-vesicular 
respiratory murmur of very feeble intensity. Little change may take place 
in these signs for months; then an acute attack of bronchitis or broncho- 
pneumonia may occur. If the latter, the same lung is affected,and a 
consolidation is added to the previous disease. This attack may not be 
very severe, but it drags on for several weeks, with slight fever and little 
or no change in the physical signs. Partial re olution may then take 



536 DISEASES OF THE RESPIRATORY SYSTEM. 

place, but the lung is left much more seriously crippled than before. In 
many cases there is a history of several such attacks, each one leaving the 
lung a little worse than it found it. 

The characteristic physical signs of chronic broncho-pneumonia are 
not usually present until the process has continued for many months, 
sometimes for several years. They may involve part of a lobe, or they may 
be present over an entire lobe, or even an' entire lung. On inspection, 
there is seen in a well-marked case, a retraction of the chest, which is 
especially noticeable when the disease is situated at the apex of the 
lung. The vocal fremitus is usually increased, but it may not be abnor- 
mal. There is marked dulness, often flatness, over the affected area, 
with exaggerated resonance over the rest of the lung. The area of flat- 
nessis not sharply circumscribed, but shades off gradually. The most 
striking thing on auscultation is the very feeble respiratory murmur ; in 
many cases the lung is almost silent. In other cases the respiration is 
distinctly bronchial in character, and, if marked bronchiectasis exists, 
it may be cavernous. Bales and friction sounds are usually absent ex- 
cept during an acute exacerbation of the symptoms, when they may be 
heard as in any attack of broncho-pneumonia. There is no displacement 
of the heart. 

The course of these cases is always uncertain. When once present 
the lesions are permanent, and there is always a tendency to increase 
rapidly or slowly, according to the child's vigour of constitution, its sur- 
roundings, and, most of all, the frequency with which exacerbations occur. 
If the disease is extensive the general health is so undermined that the pa- 
tient succumbs either to some intercurrent disease or to an acute attack 
of pneumonia ; if limited in area, the process may be arrested and the 
patient recover, always, however, to be more or less embarrassed because 
of the crippling of a part of one lung. Not a small number of these chil- 
dren ultimately die of tuberculosis, and in such cases it is always a diffi- 
cult matter to decide whether tuberculosis was present from the begin- 
ing, or whether there was subsequent infection. The classical symptoms 
which are presented by adults with bronchiectasis are rarely seen in 
young children. 

Prognosis. — From what has already been said, it will be evident that 
the prognosis in these cases is always doubtful as to the ultimate result. 
It depends on the extent of the disease, the patient's age and constitu- 
tion, and on our ability to prevent by treatment, climatic and otherwise, 
the occurrence of acute exacerbations. Under the most favourable con- 
ditions, a few patients may recover completely so far as symptoms are 
concerned ; but the majority at best remain delicate during childhood, or 
even throughout life. 

Diagnosis. — The most important thing is to distinguish between the 
simple and the tuberculous cases, and this, it must be confessed, is in the 



GANGRENE OF THE LUNG. 537 

majority impossible. Repeatedly have I seen a process proved at autopsy 
to be simple, which all who had observed the case had unhesitatingly pro- 
nounced to be tuberculous, and quite as often the opposite has been true. 
If the family history is good, if the patient lives in the country, if his 
symptoms began with a well-defined acute attack of pneumonia, if the 
seat of disease is the base of one lung, and if the examination of the 
sputum is negative, the process is probably simple. If the family history 
is doubtful or is positively tuberculous, if the patient lives in the city, and 
especially if he is an inmate of an institution or if his home is among 
the tenements, if the initial symptoms were indefinite, if the seat of dis- 
ease is the axilla, the mammary region, or the apex in front, the process 
is probably tuberculous. The discovery of tubercle bacilli in the sputum 
is, of course, conclusive. Even the course of the disease may not settle 
the diagnosis, unless there develop in the bones or in other viscera, lesions 
undoubtedly tuberculous. 

Treatment. — Nothing has any essential influence upon the disease 
except change of climate. This should be the same as for tuberculous 
cases. The treatment of the patient has for its object the maintenance 
of the general nutrition at its highest point, by careful feeding, judicious 
exercise, and by most of the measures enumerated in the chapter on Mal- 
nutrition. Cod-liver oil should be given throughout every winter season. 
The cough may be treated as in cases of chronic bronchitis. 

GANGRENE OF THE LUNG. 

Pulmonary gangrene is quite rare in children, although it is probably 
more common than in adults. It is most frequently associated with 
pneumonia. It is usually circumscribed, and in the majority of cases it is 
latent. 

Etiology.— Children of all ages may be affected ; all of my own 1 
have been under three years old, the youngest being an infant of four 
months. It occurs for the most part in children who are ill-conditioned, 
feeble, or cachectic, and often follows one of the infectious diseases, par- 
ticularly measles. In such cases it may be associated with gangrene of the 
mouth or of the vulva. It is seen in general pyaamia, and has followed 
caries of the petrous bone. Of the local causes, altogether the 1 1 fre- 
quent is broncho-pneumonia. Of nine cases which have come under 
my personal observation, six complicated acute broncho-pneumonia and 
one lobar pneumonia. It has been present in three per cenl of m) autop- 
sies upon cases of pneumonia. It may accompany pulmonary tubercu- 
losis, bronchiectasis, and pulmonary apoplexy, or it. may be due toa for- 
eign body in one of the bronchi. The immediate cause of the necrotic 
process is interference with the circulation in a pari of the Lung, which 
is usually due to thrombosis or embolism of some of the branches of the 
pulmonary artery. To this there is added the entrance of putrefa 



538 DISEASES OF THE RESPIRATORY SYSTEM. 

bacteria. In some cases the process may begin as a septic thrombosis, this 
originating in some process in a distant part of the body. 

Lesions. — According to general experience, the lower lobes are more 
frequently affected than the upper, and this is borne out by my own cases. 
The surface of the lung, rather than the central portions, are most often 
involved. 

Two forms of gangrene may be seen : the diffuse form, which affects a 
whole lobe, or even a whole lung ; and the circumscribed form, which 
occurs in a number of small scattered areas, usually from half an inch to 
two inches in diameter. The latter is the variety usually seen in children. 
In the diffuse form the lung is of a dirty green or brown colour, moist, 
and emits a gangrenous odour. In the circumscribed form, when occur- 
ring in pneumonia, the parts affected are of a gray or green colour, usually 
wedge-shaped, with the base at the surface of the lung. In the early stage 
they are not softened, and have no gangrenous odour ; later, both these 
conditions may be present, and masses of necrotic lung tissue may be 
found in a cavity with ragged walls, partly filled with fetid pus. Careful 
dissection will reveal, in many cases, the presence of thrombi in the ves- 
sels leading to the gangrenous parts. The later stages of the process are 
very rarely seen. However, in some cases the gangrenous masses may be 
coughed up and the cavity closed by cicatrization. This is more likely to 
happen where there is but one area, as when the process is due to the 
presence of a foreign body. Sometimes rupture into the pleura takes 
place, and empyema or pneumothorax follows. 

Two unique cases of necrosis of the lung have come to my notice ; 
they were in all respects similar. The surface of the lung was of a uni- 
form dark reddish-brown, and seemed to be slightly softened. On section, 
a large part of the lower lobe was of a dark-red colour and of a semifluid 
consistency, the pulmonary tissue being so completely disintegrated that it 
could be washed away with a stream of water. There was no gangrenous 
odour. No thrombosis was found in these , cases, and no explanation of 
their origin was discovered even by microscopical examination. There was 
some broncho-pneumonia present. Both cases occurred in infants suf- 
ering from marasmus. These are perhaps to be classed as examples of 
diffuse gangrene, although they differed very markedly from the form 
usually seen. 

Symptoms. — There are but two distinctive symptoms of pulmonary 
gangrene : the gangrenous odour of the breath, and the expectoration of 
masses of necrotic lung tissue. In the cases associated with acute pneu- 
monia, which include the majority of those seen, death nearly always 
takes place before there is any separation of the sloughs, and even before 
very active decomposition in the necrotic areas has occurred. Both the 
peculiar symptoms are therefore wanting, and the diagnosis is made only 
at the autopsy. This has been true of all the cases which have come 



PULMONARY COLLAPSE. 539 

under my own observation. But these patients, with one exception, were 
infants. In older children, particularly in cases secondary to the en- 
trance of a foreign body, the characteristic symptoms are more fre- 
quently seen, and there may be a third symptom — haemorrhage. This 
is present in about one fourth of the cases (Eilliet and Barthez), and 
may be fatal. The general symptoms associated with gangrene are those 
of profound depression, and often all the signs of the typhoid condition 
are present. 

From what has already been said, it will be evident that the diagnosis 
is very difficult in children, and that most cases of gangrene of the lung 
are overlooked. When the characteristic odour of the breath is present, 
conditions in the mouth from which it might arise must first be ex- 
cluded. The physical signs differ in no respect from those of ordinary 
cases of pneumonia. The termination is almost always in death. This 
is due not only to the condition itself, but to the circumstances in which 
it is seen. 

Treatment. — The general treatment is supporting and stimulating, as 
in all very severe cases of pneumonia. For the local process but little can 
be done, except the inhalation of antiseptics, of which creosote and tur- 
pentine are undoubtedly the best. 

ACQUIRED ATELECTASIS— PULMONARY COLLAPSE. 

These terms are applied to a state of the lung resembling the foetal 
condition, but which occurs in a lung which has once been expanded. 
Two varieties are met with : collapse from compression and collapse from 
obstruction. 

Collapse from Compression. — The principal cause of this form is pleu- 
ritic effusion. It may also be produced by pneumothorax, enlargement 
of the heart, pericardial effusion, deformities of the chest from rickets 
or Pott's disease, and tumours of the mediastinum or thoracic wall. In 
these conditions, on account of the external pressure, the air vesicles are 
not filled, although the bronchi are pervious. The elasticity of the vehi- 
cles tends to expel the air which they contain. This form of coll 
may be complete or partial, according to the cause. Alter it has existed 
for" a considerable time, changes may take place in the lung which ren- 
der expansion difficult or impossible. Unless, however, there are thick 
pleuritic adhesions, expansion often takes place readily after many n 
and even months, as in very many cases it is the condition of the pleura, 
rather than of the lung itself, which interferes with it. In recent 1 
only moderate force is required al autopsy to produce expansion; in 
cases it is more difficult and may be impossible. The symptoms and - 
are those of the original diseac 

Treatment is available chiefly in that form which follows plenritio 
effusion, and will be considered in the chapter on Empyema, 



540 DISEASES OF THE RESPIRATORY SYSTEM. 

Collapse from Obstruction. — This is due to two factors : blocking of 
either the large or small bronchial tubes, and feeble inspiratory force. 
The importance of collapse from obstruction as a factor in the acute dis- 
eases of the lung in infancy has, I think, been very much exaggerated. 
It is well known that whenever a large or small bronchus is completely 
obstructed by a foreign body so that the entrance of air is prevented, the 
portion of the lung to which the bronchus is distributed gradually becomes 
collapsed. If it is one of the primary bronchi which is occluded, a whole 
lung may be collapsed ; if one of the lobar divisions, an entire lobe ; if 
one of the smaller divisions, a small area, usually somewhat wedge-shaped. 
The collapse does not take place immediately, but the contents of the air 
vesicles are gradually absorbed by the blood, requiring perhaps twenty- 
four hours, or even longer. According to Lichtheim, the oxygen is first 
absorbed, then the carbon dioxide, and finally the nitrogen. The collapsed 
portion of -the lung is smaller than the inflated portions, and consequently 
is slightly depressed below the surface. It is of a dark-red colour, very 
vascular, and to the naked eye resembles a pneumonic area, which it 
may subsequently become. 

It has been the fashion since the writings of Gairdner to explain 
the development of broncho-pneumonia from bronchitis of the smaller 
tubes, through the intervention of pulmonary collapse. It has been 
assumed that the obstruction of the small bronchi from swelling of 
their walls and the accumulation of secretion, produced the same re- 
sult as the plugging of a bronchus by a foreign body. Without going 
into a full discussion of the subject, I will only say that from personal 
observations upon nearly one thousand autopsies upon infants, in which 
are included a very large number of the acute pulmonary diseases of 
all varieties, I have found very little support for this theory. In acute 
bronchitis of the smaller tubes the lumen is narrowed, but not often 
to such a degree as entirely to prevent the entrance of air. This con- 
dition of stenosis results, as a rule, in the production of emphysema, 
not atelectasis. Such, at least, has been the condition in the cases 
in which I have had an opportunity to make autopsies in the ear- 
liest stage of broncho-pneumonia, when it has developed from a gener- 
alized bronchitis of the fine tubes. It is certainly true that there are 
very often groups of collapsed air vesicles found surrounding those which 
are the seat of pneumonia, but these are neither an essential nor a very 
important part of the lesion. Anything approaching collapse of a 
large part of the lung, or even of a lobe, I have never seen, either in 
pertussis or in acute bronchitis, nor do I believe that it occurs in the 
way mentioned. 

There is occasionally seen, usually m very delicate infants or in those 
who are markedly rachitic, a form of collapse which comes on very 
gradually. It is accompanied by bronchitis affecting the tubes in the 



EMPHYSEMA. 544 

dependent part of the lung. Its seat is the lower lobes posteriorly, 
sometimes also the posterior border of the upper lobes. In general 
appearance it may resemble the congenital form of atelectasis. Under the 
microscope there is almost invariably found accompanying the collapse, 
lobular pneumonia and bronchitis of the tubes in the affected regions. 

The symptoms are much the same as in persistent congenital atelec- 
tasis. In marked cases the respiration is rapid, and there may be in- 
spiratory dyspnoea with deep recession of the chest walls, especially 
if there is rickets. There is also cyanosis of variable intensity, which 
may be constant or intermittent. There are usually present a short 
cough, feeble cry, and poor circulation with cold extremities. The tem- 
perature is not elevated, but frequently is subnormal. The physical signs 
are very uncertain. There may be slight dulness and very feeble respira- 
tory murmur over the affected areas, occasionally accompanied by moist 
rales. The course and termination are the same as those seen in some 
of the cases of congenital atelectasis. The essential point of difference 
is, that in the acquired cases the patients are often strong at birth, crying 
and breathing well, giving no signs of anything wrong in the lungs until 
the general nutrition has suffered from some other cause. The symptoms 
come on gradually. 

The following is a fairly typical case : A female infant thirteen months 
old had been under observation in the Nursery and Child's Hospital for 
several months before death. During this period she suffered a great part 
of the time from mild bronchitis. The child was extremely rachitic, and 
the chest showed deep lateral furrows. The respiration was always accel- 
erated, and on inspiration the lateral recession of the chest was at times 
extreme. There was occasionally seen slight cyanosis, and during the last 
few weeks it was constant. Death occurred quite suddenly. At autopsy 
there was found very marked vesicular emphysema of both lungs in 
front. Nearly the whole of both lower lobes were in a condition of col- 
lapse, and of a uniform grayish-purple colour. The posterior portion <>f 
the upper lobes was similarly affected, but to a less degree. With mod- 
erate force all of the collapsed areas could be completely inflated. Bron- 
chitis was present, but the pleura was normal. 

The treatment of these cases is the same as t hat outlined in the chapter 
upon Congenital Atelectasis (page 75). 

EMPHYSEMA. 

Pulmonary emphysema consists primarilj in overdistention of the ail 
vesicles. It may result in their rupture and the escape of air into the 
interlobular connective tissue of the lung. In infancy and ohildhood em- 
physema is usually associated with acute pro 

Etiology.— Cases of emphysema are divided into two groups which are 
due to quite different causes. In one -roup it iscon , and consists 



542 DISEASES OF THE RESPIRATORY SYSTEM. 

in overdistention of the air vesicles in certain parts of the lungs because 
the full expansion of other parts is prevented either because they are con- 
solidated, as in pneumonia or tuberculosis, bound down by adhesions 
from old pleurisy, or subjected to external pressure, as from chest de- 
formities due to Pott 4 s disease or rickets. In these conditions it is prob- 
able that the emphysema is produced during inspiration. It may also be 
produced by the artificial inflation of the lungs of the newly-born. 

In the second group of cases emphysema is produced by obstructive 
expiratory dyspnoea or cough. It is seen in all forms of laryngeal stenosis, 
in acute bronchitis and broncho-pneumonia, in asthma, pertussis, and 
occasionally it is produced by any condition which requires deep inspira- 
tion and holding the breath. A case has been reported to me which 
occurred in a little boy, who, while playing that he was a steam engine, 
would hold his breath for a long time and then issue short, forcible ex- 
piratory puffs. In bronchitis the obstruction may be caused by swelling 
of the mucous membrane or by an accumulation of secretion. In this 
group of cases air enters the lung, but as it can not readily escape, the air 
vesicles are distended, sometimes to such a degree that their resiliency is 
almost entirely lost. 

Lesions. — The most common form in early life is acute vesicular 
emphysema, which occurs when the force distending the air cells is only 
moderate. In this form there is dilatation of the vesicles with very slight 
structural changes, there being usually rupture of a few alveolar septa 
only (Fig. 77). Although the dilatation may be quite marked, the emphy- 
sema is not permanent. The parts most affected are the upper lobes, par- 
ticularly the anterior borders. In appearance the emphysematous lung is 
pale, sometimes almost white. The areas are prominent, and do not col- 
lapse upon opening the chest. With a lens, or even with the naked eye, 
the individual air vesicles can often be distinguished as minute pearly 
bodies, at times resembling miliary tubercles. When the disease is 
secondary to acute bronchitis or laryngeal stenosis it may affect nearly the 
whole of both lungs. 

With a greater distending force rupture of many of the air vesicles 
results, and this may give rise to interstitial or interlobular emphysema. 
At times blebs are formed, varying in size from a pin's head to a cherry. 
These are usually seen at the anterior border or at the root of the lung on 
its inner surface. Again, the air finds its way between the lobules, dis- 
secting them apart in all directions throughout the lung. Sometimes a 
large part of the surface of both lungs is seamed with irregular deep 
crevasses containing air, the largest being an inch or more in length and 
nearly one fourth of an inch wide. The most severe cases occur in per- 
tussis. On two or three occasions I have seen this form of emphysema, 
once to an extreme degree, where children had died from diseases uncon- 
nected with the respiratory tract, and where no history could be obtained 



PLEURISY. 543 

which threw any light upon the etiology of the emphysema. Rapture of 
the blebs which form at the root of the lung may lead to emphysema of 
the mediastinum, or even of the general connective tissue of the body. 
This is occasionally seen in whooping-cough and in laryngeal stenosis. 
The primary or substantive form of emphysema seen in adult life rarely 
if ever occurs in childhood. 

Symptoms. — Emphysema occurring in acute pulmonary diseases gives 
rise to no peculiar symptoms and to no physical signs except exag- 
gerated resonance upon percussion. If the patients recover from the 
original disease, the emphysema undoubtedly disappears completely in 
the course of a few weeks or months. Acute interlobular emphysema 
can not be diagnosticated during life. The lesion is of such a nature 
that complete recovery is impossible, although improvement often takes 
place. 

The treatment of emphysema is that of the original disease. 



CHAPTER VI. 
PLEURISY. 

All the common forms of inflammation of the pleura are seen in 
childhood. In the great majority of cases they are secondary to dia 
of the lung itself. Serous effusions are much less frequent than in 
adults, and under three years they are extremely rare. Purulent effu- 
sion (empyema) is, however, much more often seen than in adult life, 
and it is the most important variety of pleurisy with which the physi- 
cian has to deal. 

Whether inflammation of the pleura ever occurs as a strictly primary 
disease is still a mooted point. Cases are occasionally observed clinically 
in which both the serous and purulent forms of the disease appear to be 
primary, but these are extremely rare. Acute pleurisy may, however, fol- 
low inflammation of the lung so rapidly that it is nol easy to determine 
that the lung was first affected. In infants, extension from the lung is 
almost the sole cause. It occurs both with lobar and broncho-pneumonia, 
existing to some degree in nearly every case in which there is consolida- 
tion of the lung. Next in frequency to simple pneumonia as a can 
pleurisy are the tuberculous processes of the lung. Tuberculous pleurisy 
without tuberculosis of the lungs or the bronchial glands is of doubtful 
occurrence. Acute pleurisy is nol an infrequent complication of the 
infectious diseases, particularly scarlel and typhoid fevers, mea 
influenza. In most of tto - also it is secondary to d I the 

lung. Pleurisy in older children occasionally follows cold and i 



544 DISEASES OF THE RESPIRATORY SYSTEM. 

although it is doubtful whether in any case this is the only cause. In 
them also it may occur as a complication of rheumatism. 

The most important cause of acute pleurisy being extension from 
pneumonia, it follows that it is most frequent in the cold season, that it 
occurs more often in males than in females, and between the ages of one 
and five years. It may, however, be seen at all ages, and may even occur 
in intra-uterine life. The youngest case in which I have found extensive 
pleuritic adhesions as an evidence of previous inflammation was in an in- 
fant of three months, who died at the Kandall's Island Hospital. In this 
case firm connective tissue adhesions were found over the whole of both 

lungs. 

DRY PLEURISY. 

In infants and young children this usually accompanies pneumonia or 
tuberculous processes in the lung. In older children it may be primary. 

Lesions. — On account of the frequency with which this occurs in 
pneumonia we have an opportunity of observing it in all stages. In the 
mildest varieties it affects only the pulmonary pleura, and occurs over the 
pneumonic areas. The pleura is injected, has lost its lustre, and appears 
dull or roughened. This is due to an exudation of fibrin upon its surface. 
If the process continues, more fibrin is poured out, and there are in addition 
swelling and a proliferation of the connective-tissue cells, and an exuda- 
tion of leucocytes from the blood-vessels. The pleura is then coated with 
a layer of fibrin of variable thickness, in which are entangled pus cells 
and new connective-tissue cells. The layer of fibrin varies from the thick- 
ness of tissue paper to that of an ordinary book cover. In recent cases it 
may easily be stripped off, while in older ones it becomes organized and is 
firmly adherent. The colour of the exudate varies with the number of 
pus cells. It is gray, grayish-yellow, or yellowish-green, according as 
these cells are few or numerous. As a rule, dry pleurisy is localized, but 
the two opposing surfaces are affected. Part of the exudate is usually 
absorbed, but it is doubtful if complete recovery occurs, there being left 
behind some adhesions between the visceral and parietal layers. 

In some cases of dry pleurisy there is an excessive exudation of pus cells. 
These cases are most common in young children, and usually occur with 
pneumonia, constituting what is known as " pleuro-pneumonia." The 
process is essentially the same as in the cases just mentioned, yet the 
gross appearance differs very much from ordinary dry pleurisy. The le- 
sions have already been described under the head of Pleuro-Pneumonia 
(page 532). 

In the dry form of tuberculous pleurisy there may be only an exudation 
of fibrin, or the pleura may be covered with gray tubercles and yellow 
tuberculous nodules. These are not only seen upon the pleura, but develop 
in the exudation. In this form, which is usually chronic, great thickening 
of the pleura may take place. Both the serous and purulent effusions 



PLEURISY WITH SEROUS EFFUSION. 545 

occurring in conjunction with tuberculosis are likely to be sacculated be- 
cause of the previous existence of adhesions. 

After nearly every case of dry pleurisy there probably remains some 
slight thickening of the pleura. In certain cases there follows a chronic 
inflammation of the pleura with the production of new connective tissue, 
which results in thickening and adhesions, which may be so extensive as 
to entirely obliterate the pleural cavity. Either one or both sides may be 
affected. This form is extremely rare in childhood. 

Symptoms. — As an independent clinical disease, acute dry pleurisy has 
no existence in infancy or early childhood. The cases which are occa- 
sionally so diagnosticated have in my experience invariably proven to be 
broncho-pneumonia. In children from ten to fourteen years old, dry 
pleurisy may occur under the same conditions as in adults. 

The symptoms are sharp, localized pain, increased by full inspiration, 
sometimes tenderness upon pressure, and a short, teasing cough. The pain 
is not always felt upon the affected side, and it may be referred to the ab- 
domen. Upon physical examination, dry pleurisy is recognised by the pn >s- 
ence of a pleuritic friction sound. This is usually of a moist, crackling 
character, generally localized, and heard both on inspiration and expira- 
tion. It is quite superficial, and not changed by coughing. This form 
of pleurisy, as a rule, runs a course of a few days or a week, without con- 
stitutional symptoms. When dry pleurisy occurs as a complication of 
pneumonia it is recognised by the signs just mentioned; but it usually 
causes no new symptoms except pain. 

Treatment. — The treatment consists in counter-irritation by mustard, 
iodine, or blisters, according to the severity of the inflammation, and in 
the use of opium. Severe pain may sometimes be relieve- 1 by firmly en- 
circling the chest with a broad band of adhesive plaster. 

PLEURISY WITH SEROUS EFFUSION. 

This form of pleurisy is infrequent in children, and under three years 
it is very rare. It may occur as a complication of pneumonia, nephritis 
acute rheumatism, scarlet fever, or any of the other acnte infectious dis- 
eases. It may be tuberculous. In rare cases it appears to be primary. 
Bacteria are occasionally present in the exudation, even it. oases *hicb do 
not become purulent, but their number is usually small. The pneumo 
coccus, the streptococcus, and the tubercle bacillus an- the forms 
often seen. 

Lesions.— The early changes an- much the Bame as in dry pleurisy, 
but in addition serum is poured out from the blood 
almost from the beginning of tin- inflammation. This may be small in 
amount, or it may fill the pleural cavity. The lesions an- similar to I 
seen in adults, except that then- is apt to be more fibrin in children. The 
process usually terminates in absorption of tlieserum.hu t.as In dry pleurisy, 
42 



546 DISEASES OF THE RESPIRATORY SYSTEM. 

more or less extensive adhesions- are left behind from the fibrinous exu- 
dation. 

Symptoms. — The small serous effusions of one or two ounces, occurring 
with the dry pleurisy that complicates pneumonia, rarely cause either 
symptoms or physical signs by which they can be recognised. In the 
present connection only those cases will be discussed in which the amount 
of effusion is considerable. This form of pleurisy sometimes follows a 
w r ell-defined attack of pneumonia. Other cases come on with acute febrile 
symptoms somewhat resembling those of pneumonia, but with all the 
symptoms less severe, except the pain. After an illness of only two or 
three days the chest may be found full of fluid. In a third class the dis- 
ease comes on insidiously, with little or no fever, and often with no dis- 
tinct pulmonary symptoms except shortness of breath. There are general 
weakness, sometimes loss of flesh, anaemia, and moderate prostration ; but 
usually the patients are not sick enough to go to bed. The symptoms 
of pleurisy with effusion vary greatly. When it occurs as a complication of 
some acute infectious disease, it is often latent, and the diagnosis is to be 
made only by the physical examination of the chest. 

The usual course of the disease is for the fluid to disappear gradually 
by absorption, the case going on to spontaneous recovery. Serious symp- 
toms resulting from pressure upon the heart and lungs are not common, 
but may occur when the fluid accumulates rapidly ; hence they are most 
likely to be seen early in the attack. There may be great dyspnoea, some- 
times orthopnoea, cyanosis, weak pulse, and even attacks of syncope. 
Death may occur with these symptoms. In certain cases there is seen no 
tendency to spontaneous absorption, and the exudation may remain sta- 
tionary for months. There may then be fever, usually slight but some- 
times quite regular, with a decline in the general health, pallor and 
anaemia, which may strongly suggest the existence of pus, although this 
is not present. Others are regarded as cases of tuberculosis. 

Physical Signs. — The signs in the chest are essentially the same whether 
the fluid is serous or purulent. On inspection, there is diminished move- 
ment of the affected side, sometimes bulging of the intercostal spaces, and 
if the effusion is large, an increase in the measurement of the affected side 
of the chest. The apex beat of the heart will usually be considerably dis- 
placed if the effusion is upon the left side. It may be found at the epi- 
gastrium, at the right border of the sternum, or even in the right mam- 
mary line. In disease of the right side the displacement is less, and 
occurs only with a large effusion. It may then be found in or near the 
left axillary line. On palpation, the vocal fremitus is usually diminished 
or absent, but it may be but little changed. Percussion gives marked dul- 
ness or flatness. In a large effusion this is over the entire lung. There 
is also a sensation of increased resistance appreciable by the percussing 
finger. "With a smaller effusion there is usually flatness over the lower 



PLEURISY WITH SEROUS EFFUSION. 547 

part of the chest and dulness or tympanitic resonance above ; sometimes 
dulness is found behind and tympanitic resonance at the apex in front. 
The line of flatness may change with the position of the patient. The 
signs on auscultation are variable, and probably lead to more frequent 
mistakes in diagnosis than in any other pulmonary affection. Bronchial 
breathing and bronchial voice over the fluid are the rule in children ; they 
are generally more distinct the greater the effusion. Absence of both voice 
and breathing is sometimes met with, but it is exceptional. The bronchial 
breathing over fluid usually differs from that over consolidation, in that it 
is feebler and distant ; in some cases, however, it is indistinguishable from 
that heard over consolidation. Friction sounds may be heard above the 
level of the fluid, or when the fluid is subsiding, and there may be bron- 
chial rales. 

Diagnosis. — The most reliable signs for diagnosis are displacement of 
the heart, flatness on percussion, absence of rales and friction sounds, and 
(usually distant) bronchial breathing. In an infant, flatness should always 
lead one to suspect fluid. If there is flatness over one entire lung, the 
existence of fluid is almost certain. Between serous and purulent effusions 
a positive diagnosis is possible only by the use of the exploring needle. 
This should be employed in 'every case, as for treatment it is important to 
know at once whether or not we have a purulent effusion to deal with. 
The amount of fluid in serous pleurisy is generally less than in the puru- 
lent variety. 

Pleurisy is further to be differentiated from pneumonia, and from tuber- 
culosis. From pneumonia, the acute cases are distinguished by the lower 
temperature, the less severe prostration, and the fact that all the general 
symptoms are milder, but especially by the physical signs. The differential 
diagnosis by the physical signs between effusion and the various forms <>!' 
consolidation are considered under the head of Empyema (page 552). 

Prognosis.— These cases, as a rule, terminate in recovery, death being 
very infrequent. There is always some uncertainty about the existence of 
tuberculosis, and every patient should be closely watched for the develop- 
ment of the other signs of that disease. 

Treatment.— In the great majority of eases, only symptomatic treat- 
ment is required during the acute period. The patient should be 
in bed, and pain relieved by opium, counter-irritation, or hoi poultices. 
After the fever has ceased the patient maybe allowed to sit up, hut all 
exertion should be carefully avoided if the effusion is large. 80 
death has often occurred when this nde has been violated. The patient 
should in suitable weather be kept in the open air as much m possible. 
In the course of a few weeks the effusion usually subsidefl nnder simple 
tonic treatment. Absorption may sometimes be hastened by com 
irritation and diuretics ; but convalescence is apt to be Blow, and it may 
be several months before the health is entirely r 



548 DISEASES OF THE RESPIRATORY SYSTEM. 

The removal of the fluid by operation is indicated in the acute stage 
when it is accumulating so rapidly as to endanger life from the pressure 
upon the heart and lungs ; also when there is no tendency to absorption 
after from two to three weeks of constitutional treatment. In such cases 
nothing is to be gained by waiting, and harm may be done to the lung by 
the delay. The usual method is by aspiration. In the acute stage enough 
should be removed to relieve the patient's symptoms, aspiration being re- 
peated if necessary in twelve or twenty-four hours. In the sub-acute stage 
the removal of a portion of the fluid may be all that is required, spontaneous 
absorption of the remainder often taking place then quite promptly. A 
few cases of serous pleurisy have been incised and drained as cases of 
empyema. Scharlau (New York) operated in such a case in an infant 
two years old. The effusion came on acutely and was excessive, the chest 
having refilled very quickly after aspiration. The chest was incised and 
drained and the patient recovered in five days. In chronic cases, in which 
there are slight fever and a gradual failure of general health, the opera- 
tion of incision is by some preferred to aspiration. 

EMPYEMA. 

Fully nine tenths of the cases of empyema in children under five years 
either occur with or follow pneumonia, being usually the sequel of the 
form described as pleuro-pneumonia. In some of these cases, however, 
the pleurisy masks the pneumonia, so that the former appears to be the 
primary disease. Tuberculosis is a rare cause in early childhood, but be- 
comes more frequent after the seventh year. Empyema may complicate 
scarlet fever, measles, or any of the other acute infectious diseases. It is 
met with in pyaemia from all causes. It may occur in the newly-born as 
the result of infection through the umbilical wound or the skin. It is 
seen with suppurative inflammations of the joints and in osteo-myelitis. 
It may complicate suppurative processes in the abdomen, such as ap- 
pendicitis or purulent peritonitis. Among the local causes may be men- 
tioned traumatism, necrosis of a rib, the rupture into the pleural cavity 
of abscesses originating in the mediastinum, in the thoracic wall, or below 
the diaphragm. 

Bacteriology. — Much light upon the etiology of empyema has been 
thrown by the bacteriological investigations of the past few years, espe- 
cially by the work of Fraenkel, Weichselbaum, Levy, and Netter in 
Europe, and Prudden and Koplik in this country. Bacteriologically, we 
may divide the cases into several groups : 

1. Those containing the pneumococcus (micrococcus lanceolatus), usu- 
ally in pure culture. This is the largest group, and includes nearly all the 
cases secondary to pneumonia. The pleura is usually involved by direct 
infection from the lung. 

2. Those containing other pyogenic germs, particularly the strepto- 



EMPYEMA. 549 

coccus pyogenes and the staphylococcus. Of these the streptococcus is 
the most important. It may be found alone, but is usually associated 
with the pneumococcus. This combination is likely to be found in cases 
secondary to the pneumonia which occurs with the infectious disei 
The streptococcus and staphylococcus occur in the pleurisy of pyaemia, 
and usually also when the disease is due to the rupture of abscesses into 
the pleural cavity. 

3. The cases due to tuberculosis. In this group the presence of the 
tubercle bacillus is very often difficult to demonstrate, and it may be 
absent. From this fact the statement is made by Levy that, if no bac- 
teria can be found in a purulent exudate, tuberculosis should always be 
suspected. It is not, however, safe to conclude that under these circum- 
stances tuberculosis is always present. 

Of nineteen successive cases of empyema occurring in my own prac- 
tice, the pneumococcus was found alone in fourteen ; the streptococcus 
alone in three ; the pneumococcus and streptococcus in one ; and the staphy- 
lococcus alone in one. 

Lesions. — This is an inflammation with the production of serum, fibrin, 
and pus. In most of the cases — and the younger the child the more fre- 
quent its occurrence — empyema succeeds the form of pleurisy in which 
there is first an exudation of fibrin with an excess of pus cells (vide 
supra). As the process continues, more and more pus is poured out, 
with serum. At first the fluid collects in small pockets formed by fche 
slight adhesions. As it accumulates these are broken down, and the pleu- 
ral cavity may be filled with pus. If the original inflammation involved 
but a portion of the pleura the empyema may be sacculated. This is often 
seen even in infants. Sacculated empyema is usually posterior, but may be 
in any part of the chest. In very rare cases there may be several 
containing pus, separated by septa. This I have never seen in empyema 
following pneumonia. The cases described are those in which, in infants 
and young children, the pneumococcus is regularly found. The amount 
of fibrin is large, covers both surfaces of the pleura, and many large 
masses float in the fluid. The pus is usually thick, creamy, and odour- 
less. In another group of cases the evidences of inflammation ot the 
pleura are much less marked, and in some they may be Blight Th< 
but little fibrin in the exudate, and adhesions are rare. In this form the 
streptococcus or the staphylococcus are the organisms usually found. In 
these cases the inflammation may be purulent from the outset, and the 
pus is thinner than the preceding variety. It is rare that empyema in a 
young child results from a serous effusion which has been gradually 
verted into a purulent one. I can recall hut a Bingle install 

Even when the fluid is moderate in quantity il ia aol all at tl 
of the chest, but is generally distributed over a considerable | 
surface, and its depth at the middle and upper part of the chest ma 



550 



DISEASES OP THE RESPIRATORY SYSTEM. 



only half an inch, or even less. When the accumulation is larger, the 
lung does not float on the surface of the fluid, but the fluid surrounds 
the lung, which is compressed on all sides (Fig. 99). The heart is dis- 
placed ; the diaphragm and 
the abdominal viscera are 
somewhat depressed, and 
there may be bulging of 
the chest on the affected 
side. The amount of fluid 
in ordinary cases is from 
half a pint to two pints, 
although in neglected cases 
it may accumulate until it 
amounts to four or five 
pints. The effect upon the 
lung will depend upon the 
amount of fluid and the 
duration of the compres- 
sion. When the quantity 
is small, or when the pres- 
sure is removed early, the 
lung in most cases readily 
expands, air being forced 
into it from the opposite 
lung, especially during the 
act of coughing. If the 
pressure is great and has 
been long continued, the 
adhesions over the lung 
may become so dense and firm that expansion is difficult, and can at best 
be only partial. In such cases recession of the chest wall occurs. In very 
old cases, expansion is still further interfered with by the changes taking 
place in the lung itself, usually a low grade of interstitial pneumonia. 

In cases of empyema receiving proper surgical treatment reasonably 
early, full expansion of the lung occurs, and, with the exception of adhe- 
sions, recovery may be complete. Although wide in extent, the adhesions 
are not usually strong enough to interfere seriously with the function of 
the lung. In cases receiving no treatment, absorption of the pus is pos- 
sible, but is not to be expected. It generally seeks an external outlet ; the 
lung may be perforated and the pus evacuated through the bronchi, or 
external rupture may occur, generally in the neighbourhood of the nipple. 
In still other cases the pus may burrow along the spine, or through the 
diaphragm may reach the peritonaeum. 

Empyema is more often of the left than of the right side, the propor- 




Fig. 99. — Section of a lung to illustrate the distribution of 
the fluid in the chest in a moderately large effusion 
(diagrammatic). 



EMPYEMA. ' 551 

tion being about three to two. It is double in about three per cent of the 
cases. The most serious complication in young children is pericarditis, 
which usually occurs with emp} T ema of the left side. In older children 
the most frequent complication is pulmonary tuberculosis. 

Symptoms.— When it occurs as a sequel of pneumonia, the symptoms 
of empyema may follow those of the original disease without any inter- 
mission ; or after the temperature has been normal or nearly so for sev- 
eral days it may rise again, sometimes quite suddenly, but more often 
gradually. With this accession of fever there are other symptoms point- 
ing to an increase in the thoracic disease. After scarlet fever or other 
infectious diseases, the onset of empyema is signalized by cough, rapid 
breathing, and the other usual symptoms of pulmonary disease. In the 
cases where empyema appears to be primary, the onset is sudden, with 
high temperature and general and local symptoms resembling those of 
pneumonia. After such a beginning, the chest may be found full of pus 
by the third or fourth day. In rare cases empyema may come on with 
gradual, and even insidious, symptoms, there being only slight fever, dysp- 
noea, and cachexia. This is usually seen in older children. 

Whatever may have been the mode of onset, when the pus has been 
in the chest for some time the symptoms are fairly uniform. There are 
cachexia, pallor, anaemia, and prostration which is generally sufficient to 
keep the child in bed. The respirations are always accelerated, being 
usually from forty to seventy a minute. Cough is present ; there is dysp- 
noea, sometimes marked, but more often it is scarcely noticeable. Fever 
is exceedingly variable; it is rarely high, not often above 102° or L03 I'. : 
in many cases it is not over 100° F., and it may be absent altogether. A 
typical hectic temperature with sweating, is in my experience very rare. 
The pulse is rapid but of fair strength. There is loss of flesh, sometimes 
even emaciation and anorexia; occasionally there is diarrhoea. In chronic 
cases the general symptoms may closely resemble those of tubercult 
There may be clubbing of the fingers, albuminuria, am] even swelling 
the feet. 

Diagnosis. — The physical signs do not differ essentially from those 
present in serous effusions (page 540). Usually the history and the con- 
stitutional symptoms enable us to make a diagnosis between serous and 
purulent effusions with tolerable certainty. If the patient is under three 
years of age, the fluid is almost certain t<> be purulenl ; and from tie- third 
to the seventh year, pus is much more often found than Berura. In every 
case in which fluid is Buspected the exploring needle Bhould be used, 
cause of the great importance of an early diagnosis. The skin should be 
washed, the needle sterilize.], and the arm raised the ribs. 

Pus maynot be found because the oee ll<- ie too small, too 
it is introduced too far into the chesl ; (>>v when the layer of pus is thin 
the needle maybe pushed through thifl in'- the lung 



552 DISEASES OF THE RESPIRATORY SYSTEM. 

signs point to fluid, and if it is not found at the first trial, repeated punc- 
tures should be made until the presence or absence of fluid is definitely 
settled. In some cases eight or ten punctures may be necessary to decide 
the matter. 

Empyema is most frequently confounded with unresolved pneumo- 
nia. The mistake of regarding empyema as unresolved pneumonia is 
much more common than the reverse. The history may be the same in 
both cases, and the general symptoms may closely resemble each other. 
The differential points are, that in unresolved pneumonia there is dulness, 
usually over a single lobe, rales or friction sounds are heard, and there is no 
displacement of the heart. Empyema gives flatness over the whole lung, 
or over the lower half of the chest in front and behind, with no rales or 
friction sounds, and the heart is displaced ; and when empyema is sacculated, 
it is generally, but not always, at the base behind. In both conditions we 
may get bronchial breathing and voice. The difficulty in differentiating 
consolidation due to acute pneumonia or tuberculosis from empyema, 
generally arises from placing too much reliance upon the auscultatory 
signs. Here also the flatness, displacement of the heart, and the feeble, 
distant character of the bronchial breathing usually suffice to make clear 
the diagnosis. In pleuro-pneumonia, with an excessive exudation of fibrin, 
the signs may be identical with those of empyema, except that the heart 
is not displaced. I have once seen pulmonary tuberculosis with caseation 
of an entire lobe which gave signs that were identical with those of a saccu- 
lated empyema. It is by the exploring needle, and by that alone, that 
empyema is positively differentiated from other pulmonary diseases. Oth- 
er diseases than those of the lung may be confounded with empyema, 
particularly typhoid fever and malaria ; but from these empyema is dis- 
tinguished by the physical examination of the chest. 

Prognosis. — The outcome of a case of empyema depends upon four 
factors : the cause, the age of the patient, the duration of the symptoms, 
and the treatment. The best results are obtained in the cases that follow 
pneumonia. Tuberculosis before the seventh year is an exceedingly infre- 
quent cause, and gangrene of the lung and general pyaemia are both rare 
causes in early life. The three etiological factors last mentioned are those 
which make the prognosis of the disease in adults so serious. I can recall 
but two deaths in children over two years old which were due to empyema. 
In one case operation was refused, and in the other death was due to mul- 
tiple abscesses of the lung. The mortality in hospital cases in infants 
under one year is high — fully 50 per cent — not only because of the ten- 
der age, but because of the wretched general condition of the patients. 
Empyema in older children, seen reasonably early — i. e., within six or 
eight weeks — and receiving proper treatment, almost invariably termi- 
nates in recovery, unless the disease is double or complications exist. 
The longer operation is delayed the worse the prognosis, because the more 



EMPYEMA. 553 

difficult the expansion of the lung, the more tedious the disease, and the 
greater the likelihood of a sinus remaining. With proper early treatment 
these patients not only recover, but they recover perfectly, and in most 
cases rapidly. Eetraction of the chest and its resulting lateral curvature 
of the spine are extremely rare, and seen only in neglected cases. In the 
great majority of the cases I have seen, in which a reasonably early oper- 
ation was done, it was impossible, after the lapse of one or two years, to 
detect any difference whatever in the physical signs of the two sides of 
the chest. There is no serious disease the treatment of which is usually 
more satisfactory than acute empyema in a young child. 

Spontaneous recovery in empyema may take place by absorption ; but 
this is so rare that it is never to be expected, although there is conclu.-ivc 
evidence that it is possible. The pus may be evacuated spontaneously 
through a bronchus, rupture having taken place through the visceral 
pleura. When this occurs, a large amount of pus may be coughed up in a 
few hours, usually followed by immediate, but not always lasting, improve- 
ment. This is the most favourable of the natural terminations. External 
opening may take place, usually about the nipple. There is an area of 
redness, then a fluctuating tumour, and finally the pointing of an abscess. 
The discharge may continue for months, or even for years. External 
opening rarely occurs until the disease has lasted several months. Of 11) 
cases of empyema in children collected by Schmidt, in which a spontaneous 
discharge of pus occurred either externally or through a bronchus, there 
were 17 deaths and 2 recoveries. Empyema may burrow behind the dia- 
phragm into the abdominal cavity, appearing as a psoas abscess ; it may 
burrow posteriorly into the lumbar region ; it may rupture into the oesoph- 
agus, or through the diaphragm into the peritoneal cavity. All these 
conditions, however, are very rare. The chances of spontaneous cure in 
empyema are small. Of 32 cases, reported by Eilliet and Barthez, which 
received no surgical treatment, 21 proved fatal. The statistics of empj ems 
before the general adoption of surgical treatment are simply appalling. 
Patients were either worn out by the protracted suppuration, or died from 
amyloid degeneration, pneumonia, or tuberculosis. 

Treatment. — The medical treatment relates to the patient only; the 
disease is always to be treated surgically. Like any other acute 
empyema requires free incision and drainage with proper antiseptic pre- 
cautions. 

Aspiration as a means of cure has been almost entin Ij given op m 
New York. Unquestionably it sometimes sutliees to cure empyema, most 
frequently when it is localized. How often tin- occurs ifl mown by the 
following statistics: Of 139 cases which I collected thai m re I i ited »>v 
aspiration, 25 were cured, 8 of these bya single aspiration ; L3 died, and the 
remaining 101 were afterward subjected to other treatment Theobjec! 
to aspiration are : That it is not possible to remove all the pus; tl 



554 , DISEASES OF THE RESPIRATORY SYSTEM. 

affords no opportunity for the removal of the fibrinous masses usually pres- 
ent in large quantities in the exudate ; and, finally, that it is only a possi- 
ble means of cure. The terror caused by repeated aspirations is almost as 
great as that of incision without anaesthesia. In this way valuable time 
is lost, the disease is unduly prolonged, and the chances of success by 
subsequent incision are greatly diminished. Aspiration, therefore, is to be 
advised only for temporary relief when the amount of fluid is large and 
the symptoms are urgent. Enough pus may thus be removed to relieve 
the immediate symptoms, incision being deferred for a day or two. Even 
under these conditions its advantages over a primary incision are open 
to question. 

Puncture with a trocar and canula was formerly much practised, but 
it has almost entirely passed into disuse. 

Simple incision and drainage. — Incision is usually advisable as soon 
as the diagnosis is made. There is no advantage in delay, provided the 
patient's general condition be such as to stand the slight shock of the 
operation. The dangers attendant upon general anaesthesia are so great 
that it is better not to employ it at all. I have known four deaths to 
occur on the table during the operation, and in several other cases have 
seen very dangerous symptoms from general anaesthesia. Chloroform is 
more to be feared than ether. We should, then, rely upon the local 
anaesthesia obtained by a spray of chloride of ethyl or ether, or, better still, 
by cocaine. The most favourable point for incision is the posterior axillary 
line in the seventh intercostal space upon the right side, the eighth upon 
the left. In a case of a localized empyema, the lowest point at which pus 
can be obtained by puncture should be chosen. The incision is made in 
the middle of the intercostal space. No matter what has been found by 
puncture on previous occasions, the exploring needle should always be 
used at the time of operation and at the site of the incision before the 
latter is made. The cutaneous incision should be an inch and a half long, 
and the opening in the pleura made large enough to allow the little finger 
of the operator to pass into the pleural cavity. The haemorrhage is very 
rarely sufficient to require a ligature. Masses of fibrin presenting at the 
opening should be removed with forceps. The wound may be held open 
by forceps or a tracheal dilator, and as much of the fibrin as possible re- 
moved at the time ; or, if the patient's condition is bad, the tube may 
be immediately inserted and the dressings applied. The drainage tube 
should be of heavy rubber, fenestrated, three eighths or half an inch in 
diameter and four or five inches long. It is passed into the deepest pocket 
of the empyema. To secure it from slipping into the cavity, its outer end 
should be transfixed by a large safety-pin before its introduction. It is 
often advisable to insert two tubes side by side. This diminishes the dan- 
ger of stopping the discharge by the plugging of the tube with fibrin. 
Iodoform gauze is placed over the wound beneath the safety-pin, and a 



EMPYEMA. 



555 



compress of the same over the opening of the tube, the dressing being 
completed by a large mass of absorbent cotton and a snug roller bandage. 
The pus now slowly escapes into the dressing as the lung expands. The 
pad of gauze placed over the end 
of the tube acts as a valve, prevent- 
ing air from entering the chest, al- 
though permitting pus to escape as 
the lung is expanded by inspiration 
or by the act of coughing. When 
there is no reason for haste during 
the operation, a larger part of the 
pus may be removed before the ap- 
plication of the dressing. This 
should be allowed to escape slowly, 
the opening being closed from time 
to time by a compress. From fif- 
teen to thirty minutes should be 
consumed in evacuating the pus. 

For the first two days the dress- 
ings should be changed twice daily, 
then once a day for ten days or two 
weeks, and later at longer intervals. 
The tube is gradually shortened at 
each dressing, until, at the end of a 
week or ten days, it is reduced to 
the length of two inches. After 
the fourth or fifth day a smaller 
tube may be substituted. Usually 
by the end of the third week, and 
often by the end of the second, the 
tube may be dispensed with alto- 
gether, the tract being kept open 
by the introduction of a narrow 
strip of iodoform gauze. The time 
of redressing and the removal of the 
tube is determined by the amount 
of discharge and by the temperature. While this does do! osuallj rise 
after the second day, unless the drainage is imperfect, it may do bo when 
the lung does not expand properly, or when there is -till active di 
in the lung itself, as is no1 very uncommon in the i moel 

acutely. The drainage tube is very liable to be blocked by D 
fibrin, even when one of large Bize is need. This is the fire! thing 
suspected if the temperature rises. At each dressing it is well to remove 
the tube to see if it is clear. The mistake is often made of allowing the 




Fio. 100.— Deformity after en old empy« 

the left Bide tor which Batlander'a operation 
waa performed. Portions of flvi 
removed. From :i photograph 

after operation.) 



556 



DISEASES OP THE RESPIRATORY SYSTEM. 



drainage tube to remain too long a time, so that a sinus is kept open 
which would otherwise heal. Another is that of allowing a very large 
tube to remain for a long time ; this may cause erosion of the periosteum 
and even necrosis of a rib. Washing out the pleural cavity is indicated 
only in cases in which the pus is in a putrid condition. A single washing 
for the purpose of removing fibrin is the routine practice of some surgeons. 
For this a warm sterilized salt solution should be used. Personally I have 
not found this necessary. Eepeated irrigations should on no account be 
employed. The usual duration of the discharge in cases treated by simple 
incision is from three to six weeks, the average being about five weeks. 
The earlier the operation the shorter the course, because of the facility 
with which the lung expands. 

Resection of a rib. — Many of the best surgeons favour this as a routine 
procedure, with the belief that with the larger opening which is thus 

made, more perfect drainage 
is secured, that masses of 
fibrin can be removed with 
greater facility, and that it 
is altogether a more certain 
and efficient means of treat- 
ment than is a simple incis- 
ion. While admitting some 
of the advantages claimed, 
my own experience has been 
that in the great majority of 
recent cases in young chil- 
dren simple incision with 
drainage is all that is re- 
quired. Eib resection is ne- 
cessary if there is overlap- 
ping of the ribs, or if the in- 
tercostal spaces are so nar- 
row as not to allow the in- 
troduction of a good-sized 
drainage tube. These are 
usually the cases in which the disease has lasted much longer than the 
average. One inch of rib is all that it is necessary to remove. The peri- 
osteum is preserved, and there is rarely any permanent deformity. 

In chronic cases, or those which have been long neglected, some fur- 
ther operative treatment is often necessary. Some of these are cases 
which have opened spontaneously and discharged for many months before 
coming under observation. The lung is so bound down by firm adhesions 
that further expansion is impossible, and even after the chest has receded 
to its utmost, so that the ribs are in contact, there still remains a cavity 




Fig. 101. 



-James' apparatus for expanding the lung 
after empyema. 



EMPYEMA. ;,;,; 

which can not close. For such cases the only hope is in an operation by 
which portions of several ribs are removed, thus allowing a greater collapse 
of the chest. This is known as thoracoplasty, or Estlander's operation. 
The operation is of itself a serious one, and only to be advised as a last 
resort in inveterate cases. By it, however, life may be saved in some that 
are otherwise hopeless. Such an operation is, of course, always followed 
by very great deformity (Fig. 100). 

Methods of inducing expansion of the lung. — In most of the - 
particularly the recent ones, complete expansion of the lung takes place 
without any difficulty, the chief agent being the cough. In some a 
this may be insufficient. The apparatus shown in the accompanying cut 
(Fig. 101), devised by James (New York), serves at the same time as a toy 
for the child's amusement and a most efficient means of inducing forced 
expiration. One bottle is placed a few inches higher than the other, and 
the child blows a coloured fluid from the lower into the higher bottle, 
allowing it to siphon back. By raising the second bottle, a greater ex- 
piratory force is required. This may be regulated at will. The apparatus 
may be used for a few minutes several times a day, and particularly in 
cases of long standing it is of great assistance in producing pulmonary 
expansion. Blowing soap bubbles often answers the same purpose. 



SECTION Y. 

DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

PECULIARITIES OF THE HEART AND CIRCULATION IN EARLY 

LIFE. 

The Foetal Circulation. — During the latter part of foetal life the circu- 
lation may be briefly described as follows : The purified blood comes from 
the placenta through the umbilical vein. Entering the body, it divides at 
the under surface of the liver into two branches, the smaller one, the ductus 
venosus, communicating directly with the inferior vena cava ; the larger 
branch joining the portal vein, so that its blood traverses the liver, and 
then entering the inferior vena cava through the hepatic vein. From the 
inferior vena cava the blood enters the right auricle, joining that returned 
from the head and upper extremities by the superior vena cava. A part 
of the blood now passes directly into the left auricle through the foramen 
ovale ; the remainder through the tricuspid orifice into the right ventricle. 
As the requirements of the pulmonary circulation are not great, only a 
small part of the blood is sent through the pulmonary artery to the 
lungs ; the greater portion passes from the pulmonary artery through the 
ductus arteriosus into the aorta, joining here the blood from the left ven- 
tricle. The blood thus finds its way from the right heart to the left, only 
in small part by way of the lungs, the greater part passing directly from 
the right auricle to the left, or from the right ventricle into the aorta 
through the ductus arteriosus. From the aorta, the blood reaches the 
placenta through the umbilical arteries, which are a continuation of the 
hypogastric arteries, which in turn are given off from the internal iliacs. 

Changes in the Circulation at Birth. — With the ligature of the umbil- 
ical cord, the circulation through the umbilical vein and arteries and the 
ductus venosus ceases. With the establishment of respiration and the 
consequent increased demands made by the pulmonary circulation, the 
blood ceases almost at once to pass through the ductus arteriosus, and very 
soon through the foramen ovale. The umbilical vessels during the first 
few days of life are filled with small thrombi, which become organized. 
By the end of the first week, these vessels, as well as the ductus venosus, 
are usually closed at their extremities, although they may remain patulous 
throughout the greater part of their extent for several weeks. They sub- 
sequently atrophy to the condition of small fibrous cords. For some weeks 

558 



THE HEART AND CIRCULATION IN EARLY LIFE. 



559 



before birth the circulation through the foramen ovale is slight, it being 
gradually obstructed by the growth of a septum which nearly fills the space 
at birth. After the first week of extra-uterine life very little, if any, blood 
passes through it, although complete closure of the foramen often does 
not take place until the middle of the first year. In fully one fourth of 
the autopsies I have made upon infants under six months old, there have 
been found minute openings at the margin of the foramen ovale, but they 
are usually oblique, and closed by the valvular curtain so as effectually to 
obstruct the current of blood. The ductus arteriosus is -first closed by a 
clot, which becomes organized and blends with the products of a prolif- 
erating arteritis. It is rarely found open after the tenth day, and by the 
twentieth it is almost invariably obliterated. 

The Pulse. — The pulse in early life is not only more frequent, but it is 
very much more variable than in adults. The following is the average 
pulse-rate in healthy children during sleep or perfect quiet : 

Six to twelve months 105 to 115 per minute. 

Two to six years 90 " 105 " ** 

Seven to ten years 80 " 90 " 

Eleven to fourteen years 75 " 85 " 

The pulse is a little more frequent in females than in males, and more 
frequent when sitting than when lying down. Muscular exercise or ex- 
citement increases the pulse-rate by from twenty to fifty beats. Very 
trivial causes disturb not only the frequency but the force of the pulse. 
The pulse in young infants may be irregular even in health and daring 
sleep. When rapid, it is frequently irregular without any meaning. No 
dicrotism is seen in the pulse wave of early infancy, according to Blanche.* 

The circulation is much more active in infancy than in later childhood ; 
thus, according to Vierordt, the entire round of the circulation is accom- 
plished in the newly-born in twelve seconds ; at three years, in fifteen B6C- 
onds ; in the adult, in twenty-two seconds. 

Size and Growth.— The relative size of the heart is slightly greater in 
infancy than in later life, it being smallest at about the seventh year. 
The average weight at the different periods of life is as follows : f 



Age. 


Ounces. 


Grammes. 


Wrl^'llt 


Birth 


0-50 
L-25 
1-87 

3-80 
5-84 
8-60 


14] 

I i4 ) 

166 

241 


l to 


2 years 

3 " 




7 « 


l to 


14 « 


1 It 


Adult 


1 1 








* See tracings in Archives of Pediatrics, vol. v, p, 

f The figures in infancy are fn.m one hundred and fifty-Aye obwrattoni rnad< 
the New York Infant Asylum ; the others are taken from SahlL 



560 DISEASES OP THE CIRCULATORY SYSTEM. 

The growth of the heart is rapid during the first three years, and 
nearly proportionate to that of the body. It is slowest from the third 
to the tenth year, and most rapid from the eleventh to the fifteenth 
year. At birth, the thickness of the right ventricle is very nearly the 
same as that of the left, the ratio being 6 : 7. The left ventricle, how- 
ever, grows very much more rapidly than the right, so that at the end 
of the second year the ratio is 1:2, which is nearly that of the rest of 
childhood. 

Position of the Apex Beat. — In the infant the heart is placed some- 
what higher, and occupies a position a little nearer the horizontal than in 
the adult. This is partly due to the higher position of the diaphragm. 
The apex beat is therefore higher and farther to the left than in adult 
life. According to the observations of Wassilewski and Starck, whose 
combined examinations with reference to this point were made upon over 
2,100 children, the apex beat is, as a rule, outside the mammary line until 
the fourth year ; if it is less than one third of an inch beyond the nipple, 
it can not be considered abnormal. From the fourth to the ninth year, 
the apex beat is in or near the mammary line. After the thirteenth year, 
under normal conditions, it is invariably within that line. During the 
first year, the apex beat is usually found in the fourth intercostal space ; 
from the first to the seventh year, it is found with about equal frequency 
in the fourth and the fifth spaces ; after the seventh it is usually, and after 
the thirteenth year it is always, when normal, in the fifth space. The 
position of the apex beat may be considerably modified by severe deformi- 
ties of the chest resulting from rickets, Pott's disease, or lateral curvature 
of the spine. 

Examination of the Heart. — Inspection. — Bulging of the prsecordia is 
a frequent and important sign of cardiac disease during childhood. The 
cardiac impulse is generally weaker than in the adult, and often it is diffi- 
cult to locate the apex beat owing to the thick layer of adipose tissue 
covering the chest. 

Palpation. — This is usually a much more satisfactory method than is 
inspection for determining the position of the apex beat. For this pur- 
pose the child should be in the sitting posture, with the body inclined 
slightly forward. Great displacement of the apex beat is always signifi- 
cant, and should lead one to suspect pleuritic effusion ; lesser degrees of 
displacement to the left indicate hypertrophy, especially of the left ven- 
tricle ; to the right, hypertrophy of the right ventricle, usually with a con- 
genital malformation. 

Percussion. — This is best done by means of the percussion hammer. 
A light blow should be used, on account of the thinness and elasticity of 
the chest walls. The outline of the area of " relative cardiac dulness," 
especially in small children, is proportionately larger than in the adult. 
This may lead to the mistaken opinion that the heart is enlarged, when it 



THE HEART AND CIRCULATION IN EARLY LIFE. 



561 



is really of normal size. According to Sahli,* the limits of this area are as 
follows : Above, the second space or lower border of the second costal car- 
tilage ; to the right, at the para-sternal line, sometimes slightly beyond it ; to 
the left, at or slightly beyond the mammary line, this depending upon the 
age of the child. The lower border is indeterminable on account of the liver. 

The area of " absolute cardiac dulness," or that part of the heart un- 
covered by the lung, resembles in shape the same area in the adult, but it 
is relatively larger. Its upper 
limit is the upper border of the 
third intercostal space, some- 
times the third costal cartilage ; 
it extends to the left to a point 
between the para-sternal and the 
mammary lines, and to the right 
as far as the left border of the 
sternum. These two areas will 
be readily understood by refer- 
ence to the accompanying dia- 
gram (Fig. 102). 

Auscultation. — This is of lit- 
tle value unless the child is quiet. 
The preferable position is the 
sitting posture. For an accu- 
rate diagnosis the stethoscope is 
indispensable, but auscultation 
should always be practised with 
the naked ear as well. The 
rhythm and rapidity of the 
child's heart action are much 
more easily disturbed than are 
the adult's, and such disturbances are consequently much less significant 
The rapidity of the heart in infancy is ordinarily bo great as to make it 
practically impossible to distinguish between diastolic and presystolic mur- 
murs. Normally, the loudest sound is the first sound at the apex; the 
weakest sound is the second sound at the aortic orifice, ^ccordii 
Hochsinger, the accentuation of the child's heart-sonndfi ifi upon tin- first 
sound, and not upon tin- second, as in the adult 

In consequence of the small size and the thin walls of tin- ch< 
sounds, both normal and pathological, appear relatively louder than in the 
adult, and the area of diffusion is therefore much greater. Thus it 
frequent occurrence for murmurs to be heard all over the chest both iu 
front and behind. 




Fig. L02. — Showing urc;i> of cardiac dulness: 
the mammary line; 6, the para-sternal line; /.. 
the upper border <>t' the liver. The B] 
closed By the d<>ttr<l line represents the area <>t 
relative dulness ; tin- heavily shaded area, thai 
of absolute dulness. (After Sahli, alight 
fted bj I Q| 



43 



* Topograplus.hr Percussion in 



562 DISEASES OF THE CIRCULATORY SYSTEM. 

Eeduplication of the heart sounds, in consequence of the valves of the 
two sides not closing exactly together, is not uncommon in children, and 
may be due simply to excitement. During the first four years of life 
nearly all the abnormal murmurs heard are systolic. 

Accidental murmurs may be due to anaemia and other blood condi- 
tions, and, although not so common as in older patients, they are by no 
means rare even in infants. 



CHAPTER II. 

CONGENITAL ANOMALIES OF THE HEART. 

Etiology. — The causes of congenital anomalies of the heart may be 
grouped under three general heads : 

1. Malformations resulting from imperfect development of certain 
parts of the heart, most frequently one of the septa. Either the ventricu- 
lar or the auricular septum may be affected, or that dividing the pulmo- 
nary artery from the aorta. Such failure in development perpetuates condi- 
tions which are normal in the early months of foetal life. There may also 
be atresia of any one of the orifices, absence of one or more of the valvular 
leaflets, or of any one of the large vessels. 

2. Foetal endocarditis. The effects of this condition vary according to 
the time of its occurrence. It is almost invariably of the right side, most 
frequently affecting the pulmonic valves. Valvular disease in foetal life 
leads not only to hypertrophy and dilatation, but also interferes with 
the normal development of the heart by preventing the closure of the 
auricular or ventricular septum or the ductus arteriosus, these being kept 
open by way of compensation. 

3. Persistence of foetal conditions, such as the foramen ovale or ductus 
arteriosus. This may be the result of valvular disease, as previously 
stated, or of some condition of the lungs, such as atelectasis. 

Lesions. — In the following table are given the lesions found in two 
hundred and forty-two cases, which I have collected from medical litera- 
ture : 

The frequency of the different lesions in 2J±2 autopsies upon cases of 
congenital cardiac anomaly. 

Defect in the ventricular septum 149 cases ; only lesion in 5 cases. 

Defect in the auricular septum or patent foramen 

ovale 126 " " " 9 " 

Pulmonic stenosis or atresia 108 " " " 6 " 

Patent ductus arteriosus 68 " " "3 " 



CONGENITAL ANOMALIES OF THE HEART. 



►63 



in 




" 


» 


" 


.. 


'« 


M 


« 


u 


" 


" 


" 


•• 


u 


•• 


" 


" 


M 


.. 



Abnormalities in the origin of the great vessels . 45 cases ; only lesion 

Pulmonic insufficiency 17 " 

Tricuspid insufficiency 6 " " 

Tricuspid stenosis or atresia 3 « " 

Mitralinsufficiency 1 » •« 

Mitral stenosis or atresia 6 " " 

Aortic insufficiency 1 

Aortic stenosis or atresia 6 <k " 

Transposition of the heart .... 2 " 

Ectocardia 1 



The most frequent associated lesions. 

Pulmonic stenosis, with defect in the ventricular 

septum 92 cases ; only lesion in 20 < 

Pulmonic stenosis, with defect in the auricular 

septum 52 " " " 8 " 

Defects in both septa 82 " " •• 1 7 •• 

Pulmonic stenosis and defects in both septa 36 4i " •• 21 

From this table it will be seen that, in the great majority of rases. 
several lesions are present, the most frequent combinations being pul- 
monary stenosis with defective ven- 
tricular septum, pulmonic stenosis 
with defective auricular septum, 
the three lesions associated, or the 
first two with a patent ductus arte- 
riosus. 

Defect in the ventricular sep- 
tum. — This is the most frequent 
lesion in congenital cardiac disease, 
and in half the cases was associated 
with pulmonic stenosis. The de- 
fect is generally at the upper part 
of the septum (Fig. 103). It is 
usually from one fourth to one half 
an inch in diameter, but not infre- 
quently there is a large defect, and 
the septum may be entirely absent. 
the heart then consisting of but 
three cavities— two auricles and 
one ventricle. If the auricular Bep- 
turn also is wanting, as is often the 
case, the heart has but two cavities. 

Abnormalities in the origin of the greal vessels are frequently as 
The pulmonary artery and the aorta may be given ofl from tie- common 
ventricle, or the aorta may arise partly from one ventricle and partly I 
the other. If pulmonic stenosis or atresia is present, the opening in the 




Fig. 108, Congenital cardiac dUeaw 
ventricle Lb shown with ;i defeci in tl 
tr'h'wlar septum, tin- openii 
neath the ;i->rti<- valve From a 
Lng in tli' !'• 






564 DISEASES OF THE CIRCULATORY SYSTEM. 

ventricular septum is conservative, affording a channel for the passage of 
blood from the right to the left side of the heart. 

Patent foramen ovale, or defect in the auricular septum. — Although 
this is one of the most common congenital malformations, it is not one of 
the most important. It rarely occurs alone, but is frequently found with 
pulmonic stenosis or a defect in the ventricular septum. Small oblique 
openings in the auricular septum — usually at the foramen ovale — are not 
infrequently met with in autopsies upon young infants, but they are of no 
importance. In pathological conditions the opening is from one fourth 
to one inch in diameter, and there may be more than one opening. A de- 
fect in this septum is frequently secondary to pulmonic stenosis, or it may 
be a failure in development. A patent foramen ovale may be due to 
atelectasis. 

Patent ductus arteriosus. — As a solitary lesion this is rare, but it is 
frequently associated with pulmonic stenosis, usually with a defect in one 
or both septa. It is then one of the channels by which the blood may find 
its way to the lungs when the pulmonary orifice is obstructed. It is not 
a malformation, but simply the persistence of a foetal condition usually 
necessitated by other changes in the heart. 

Pulmonic stenosis. — This is one of the most frequent and most im- 
portant lesions. It may be due to foetal endocarditis, or to a mal- 
formation. If the former, there is usually stenosis ; if the latter, there 
may be atresia. It is often a primary lesion, and when marked it is 
always accompanied by other changes, most frequently by a defect in one 
or both septa or by a patent ductus arteriosus. This is important, as be- 
ing more constantly associated with cyanosis than is any other congeni- 
tal lesion. The amount of obstruction varies from a slight narrowing 
of the orifice to complete atresia. If there is atresia, the pulmonary artery 
is very small, and may be rudimentary. 

Pulmonic insufficiency. — This lesion is relatively rare. It is usually 
the result of foetal endocarditis, but there may be absence of the pulmo- 
nary valve. It is most frequently associated with a defect in the ven- 
tricular septum. 

Tricuspid, mitral, and aortic disease are all very infrequent and usu- 
ally seen in cases with multiple defects. Atresia or stenosis is much more 
common than insufficiency. 

Abnormalities in the origin of the large vessels. — These are quite fre- 
quent ; but, as will be seen from the table, they are always associated with 
other lesions. Three forms are seen : (1) Transposition of the large vessels 
— the pulmonary artery is given off from the left, and the aorta from the 
right ventricle. (2) Both arteries arise from a common trunk. This is 
usually due to an incomplete development of the lower part of the sep- 
tum dividing the two arteries. Usually the pulmonary artery appears to 
be a branch of the aorta. This condition is frequently associated with 



CONGENITAL ANOMALIES OF THE HEART. 535 

other abnormalities, often with so large a defect in the ventricular septum 
that there is really hut one ventricle. (3) The aorta has an abnormal 
origin, arising from the right ventricle, or partly from both ventricles. 
This also is associated with a large defect in the ventricular septum. 
When described as arising from both ventricles, the aorta is usually given 
off directly above the line of the septum. 

In addition to these main deformities, there are many others which 
need not be more than mentioned. An abnormality in the number of 
valvular segments is quite a frequent occurrence, but does not usually 
impair the valve's function. In rare cases a valve is rudimentary, and 
it may be entirely absent, generally at the pulmonic or tricuspid orifice. 
Absence of the right auricle and absence of the pericardium have been 
recorded ; also opening of the pulmonary veins into the right auricle, and 
a single pulmonary artery. In one case in the series there was ectocardia, 
this being associated with a congenital fissure of the sternum. 

Transposition of the heart, or true dextro-cardia, was recorded but 
twice in this series of cases. It was, however, simulated in several others, 
including one of my own, where the apex beat was to the right of the 
sternum. There was in this case great hypertrophy of the right ventricle 
with a rudimentary ventricular septum. 

Secondary lesions. — Since the one condition which nearly all of the 
congenital malformations of the heart have in common is a persistence of 
one or more of the foetal conditions in which the right ventricle doc- 
most of the work, it is usually found hypertrophied. It is in most 
cases accompanied by some dilatation, and often there is dilatation of the 
right auricle. Changes in the wall of the left heart alone are exceedingly 
rare. In four cases there was evidence of malignant endocarditis, which 
was the cause of death, all but one of these patients being adults. 

Symptoms. — The symptoms of congenital cardiac disease are usually 
manifested soon after birth, although this is not always the case. Of 128 
cases in which the time of the first symptoms was noted, they were con- 
genital, or appeared during the first month, in 85; after one month and 
during the first year, in 18; from one to sixteen years, in L5; while in 10 
no symptoms were observed until after puberty. Congenital cardiac dis- 
ease is one of the causes, but not a frequent one, of death during fche firsl 
few days of life. This may be directly due to convulsions, asphyxia, or 
syncope. 

The most striking objective symptom is cyanosis. This was noted in 
88 percent of the cases in which historic- were given. Congenital cardiac 
disease is very apt to be overlooked when cyanosis Is absent, as il maj be 
even with very serious lesions. Cyanosis may he slight ami noticed only 
upon exertion, as upon coughing or crying, or it may he intense and 
stant, giving the skin a dark, leaden colour, an. 1 the mucous memb 
of the mouth a raspberry hue. The view that cyanosis depends upon an 



DISEASES OF THE CIRCULATORY SYSTEM. 




Fig. 104. — Clubbing of the fingers in congenital heart disease. 
(From a boy five years old.) 



admixture of arterial and venous blood is generally discredited. In the 
great majority of the cases at least, the explanation is a deficient oxi- 
dation of the blood 
in the lungs, owing 
to some interference 
with the pulmonary 
circulation. In 63 
per cent of the cases 
of cyanosis in the se- 
ries, there was found 
pulmonic stenosis or 
atresia, or a small 
pulmonary artery. 
Cyanosis is of much 
value in diagnosis, as 
it is ' rarely seen in 
acquired cardiac dis- 
ease. The degree of 
cyanosis and its con- 
stancy are of some 
importance in deter- 
mining the gravity 
of the lesion, although these alone are not to be depended upon. Another 
frequent symptom is the enlargement of the terminal phalanges known 
as clubbing of the fingers (Fig. 104) and toes. This enlargement, which 
usually involves all the phalanges, is probably due to venous obstruction. 
Occasionally there are seen dyspnoea, oedema of the lower extremities, 
dropsy of the serous cavities, and haemorrhages, particularly haemoptysis 
and epistaxis. 

Diagnosis. — The most diagnostic features of congenital cardiac disease 
are cyanosis, the presence of cardiac murmurs, and signs of enlargement 
of the right heart. 

Murmurs were present in four fifths of the cases in which histories 
were given. The most characteristic is a systolic murmur, loudest at the 
left base and diffused over a large area. A systolic murmur only was 
heard in GO cases, a double murmur in 11, a diastolic and a presystolic 
in one case each. A systolic murmur may be due to pulmonic stenosis, 
deficient ventricular septum, patent ductus arteriosus, mitral regurgitation, 
tricuspid regurgitation, or aortic stenosis. Since these conditions are very 
often associated, it is difficult to tell upon which one the murmur depends. 
In over two thirds of the cases in which the murmur was localized it was 
at the base of the heart, and in the great majority of these it was loudest 
at the left base, in the second or third space at the border of the sternum 
and transmitted toward the left shoulder. Apex murmurs were heard in 



CONGENITAL ANOMALIES OF THE HEART. 



567 



but one fourth of the cases. The murmurs are usually loud, rough, and 
often out of proportion to the other signs present. Frequently they may 
be heard all over the chest, both in front and behind. In a young child, 
a very loud murmur with cyanosis is almost diagnostic of congenital 
ease, since in acquired disease loud murmurs are nearly always at the apex 
and accompanied by marked hypertrophy. 

Enlargement of the right heart, chiefly from ventricular hypertrophy, 
was present in 86*5 per cent of the cases. In about one half of these there 
was hypertrophy of the left ventricle, but this was rarely seen alone. The 
signs of hypertrophy of the right ventricle are : dulness extending to the 
right of the sternum, displacement of the apex beat to the right, epigastric 
pulsation, and sometimes bulging of the lower portion of the sternum. 

A diagnosis of the precise nature of the malformation is very difficult, 
and in the great majority of cases only a probable diagnosis is possible. 
Xearly all the cases are complex, and the variety of combinations is wry 
great. A study of the histories and autopsies of the cases in this Be 
reveals many apparently contradictory facts. Loud murmurs are some- 
times heard which are difficult to explain by the lesions, and murmurs 
may be absent where there is every reason for expecting their presence, 
as in a case recently under my observation. Certain lesions like aortic 
stenosis, mitral stenosis, and mitral regurgitation may be accompanied by 
the same signs as in acquired disease. With reference to the other con- 
ditions, I can not do better than give the more frequent clinical symp- 
toms with the results of the autopsies in the series of cases which I have 
collected. 

A systolic murmur at the base, with cya?iosis. — This is the mosi com- 
mon combination met with, and was present in about one third of all the 
cases. In over 80 per cent of the cases with these symptoms, pulmonic 
stenosis was found. The remainder were complicated cases «>f qui! 
wide variety. Pulmonic stenosis was usually associated with a defect in 
one of the cardiac septa, or a patent ductus arteriosus. 

A systolic murmur without cyanosis.— In the cases followed to autopsy 
this was not a frequent combination, bei n g noted hut six times, and usu- 
ally dependent upon a defect in the ventricular septum without pulmonic 
stenosis, or upon tricuspid regurgitation. Judging from my own clinical 
experience, a systolic murmur without cyanosis ifl more common thai 
indicated by these figures. 

A systolic murmur at fh» <//,<:,• with cyanosis. — Of the *ith 

this combination, all were examples of complex malformation, 
frequent lesions being a defect in the auricular Beptum, trs >n of 

the great vessels, and patent ductus arteriosus. 

Cyanosis without murmurs was noted fourteen time* It ind 
either pulmonic atresia or the transposition 
vessels. 



568 DISEASES OP THE CIRCULATORY SYSTEM. 

Diastolic murmurs were heard in two cases, and depended upon pul- 
monic insufficiency. 

A presystolic murmur was noted in a single case. It was localized at 
the right base, and the only lesion was a patent foramen ovale. 

Absence of loth cyanosis and murmurs was recorded in five cases. 
The lesions found were : atresia of the aorta, both arteries arising from 
the right ventricle, or defective septa. 

It will be seen that about the only cases in which a fairly positive 
diagnosis can be made is pulmonic stenosis with a deficient ventricular 
septum. Enlargement of the right heart, being common to nearly all 
the varieties, is of no diagnostic value. 

Diagnosis of congenital from acquired disease. — Congenital disease 
may be suspected if the patient is under two years of age ; if there is no 
history of previous rheumatism ; if the murmur is atypical in its location, 
character, or transmission ; if there is a very loud murmur at the base ; if 
there is cyanosis; and if there is evidence of enlargement of the right 
heart. 

Diagnosis of congenital from anwmic murmurs. — This is often a more 
difficult matter than to decide between congenital and acquired disease. 
From a murmur alone one should be very cautious in making a diagnosis 
of cardiac malformation in a very anaemic infant. Anaemic murmurs are 
systolic, basic, unaccompanied by enlargement of the heart ; usually heard 
in the carotids, often in the subclavian arteries, but are seldom so loud as 
those due to malformations. In some cases it may be necessary to watch 
the effect of treatment or the course of the disease before deciding the 
question. 

Prognosis. — Of 225 cases, 60 per cent were fatal before the end of the 
fifth year, and nearly one half of these during the first two months ; while 
16 per cent of the cases lived over sixteen years, and 8 per cent over thirty 
years. The prognosis in any given case is to be made from the general 
condition of the patient and how well the circulation is carried on, rather 
than from the intensity of the cyanosis or the character of the murmur, 
although extreme cyanosis is always unfavourable. 

In the cases fatal soon after birth the usual lesions are large defects in 
the septa, transposition of the great vessels, or pulmonic atresia. In five 
of twenty-three cases dying thus early, the heart had but two cavities. Le- 
sions which are compatible with the longest life are minor septum defects, 
and pulmonic stenosis which can be compensated for by hypertrophy of the 
right ventricle. Many exceptional instances are recorded in which patients 
have lived a long time in spite of extreme deformities. One child with 
transposition of the pulmonary artery and aorta lived two and a half years. 
Tiedmann's case lived eleven years with a heart consisting of three cavities. 
— two auricles and one ventricle — and with constant cyanosis. In three 
cases reported by Rokitansky, the patients lived over forty years with rudi- 



PERICARDITIS. 



569 



mentary auricular septa and no cyanosis mentioned. Gelpke's case had 
cyanosis, and lived twenty-seven years with rudimentary auricular and 
ventricular septa, and with no tricuspid opening. 

Treatment. — No treatment is of the slightest avail in diminishing the 
amount of deformity or promoting the closure of any of the abnormal 
openings. All cases are to be treated symptomaticallv. 



CHAPTER III. 

PERICARDITIS. 

Inflammation of the pericardium is a rare disease in infancy and 
early childhood, only two cases being seen in seven hundred and twenty- 
six consecutive autopsies at the New York Infant Asylum. In later 
childhood the disease is more frequent. In its etiology, symptoms, and 
course it resembles quite closely the same disease in adults. 

Etiology. — Of 69 cases of pericarditis in children under fourteen years 
of age, 24 occurred before the third year, 12 between the third and Bev- 
enth years, and 33 between the seventh and fourteenth years. It has been 
seen in the newly-born, and has been found even in the foetus. 

Pericarditis is almost invariably a secondary disease, following ( 1 ) 
pleurisy or pleuro-pneumonia ; (2) acute rheumatism; (3) acute infec- 
tious diseases, especially scarlet fever; (4) pyaemia; (5) tubercul 
local causes. The relative importance of these causes differs with the 
of the child. In infancy and early childhood most of the cases compli- 
cate disease of the lung or pleura, usually of the left side. Attn- the fourth 
year rheumatism takes the first place as an etiological factor. Pericar- 
ditis is then generally associated with endocarditis, and may precedi 
follow the articular manifestations of rheumatism. Following Bcarlel fever, 
pericarditis generally occurs in connection with nephritis or multiple joint 
inflammations. In typhoid fever, also, it is usually associated with pneu- 
monia or joint lesions. Pyamiia may be a cause in the newly-born, or il 
may occur in connection with disease of the bones or joints in older chil- 
dren; in both it is usually associated with similar lesions of other serous 
membranes. Tuberculous pericarditis is more frequent after the third 
year, and is generally secondary to pulmonary tuberculosis Among the 
local causes maybe mentioned traumatism, ulceration of a foreign body 
from the oesophagus into the pericardium, disease of the sternum, rib 
vertebras, and abscesses resulting from cheesy bronchial lymph do 

Lesions. — 1. Pericardia) transudations, or an increase in the n< 
pericardial fluid, are met with in many conditions in which there 



570 DISEASES OF THE CIRCULATORY SYSTEM. 

very marked degree of anaemia, general dropsy, or a weak heart, particu- 
larly of the right side. Generally from one and a half to two ounces of a 
clear serum are found in the pericardial sac. 

2. External or mediastinal pericarditis is always associated with 
mediastinal pleurisy, and results in more or less extensive adhesions of 
the pericardial and pleural surfaces, with an increase in the connective 
tissue of the mediastinum. It is often a tuberculous process. When 
severe, it may cause compression of the large blood-vessels, and seldom in 
any other way produces symptoms. With this form there may be inflam- 
mation of the internal layer of the pericardium. It is only inflammation 
of the internal layer which is ordinarily considered as pericarditis, the 
other form being preferably classed as mediastinitis. 

3. Dry pericarditis. — This may be either general or localized. If the 
latter, it is more often seen at the base than at the apex of the heart. The 
two opposing surfaces are usually involved. As a result of the inflamma- 
tion they are coated with fibrin, which may be partly absorbed, but usu- 
ally leaves behind bands of adhesions of greater or less extent. From re- 
peated attacks there may result complete obliteration of the pericardial sac. 

4. The sero-fibrinous form— pericarditis with effusion. — This is the 
most common variety. The heart appears roughened from the exudate 
which often completely covers it, forming bands which extend from one 
surface to the other. The serum may be clear, or contain flakes of lymph, 
and varies in amount from a few ounces to a pint. In cases terminating 
in recovery there is gradual absorption of the serum and part of the 
fibrin, but adhesions more or less extensive always remain. 

5. Purulent pericarditis. — If the inflammation is set up by a foreign 
body ulcerating into the sac, by the rupture of a mediastinal abscess, or 
by general pyaemia, the process may be purulent from the outset. More 
frequently, however, in purulent pericarditis there is first an abundant 
exudation of fibrin with pus cells in its meshes, and subsequently the 
pouring out of fluid pus, precisely as in empyema, with which it is very 
often associated. If death occurs in the early stage, both surfaces of the 
pericardium are found coated with a thick exudate of greenish -yellow 
lymph, but little or no fluid pus may be present. At a later period the 
pericardial sac contains pus, which may vary in amount from a few 
ounces to one or two pints. Purulent pericarditis, which is secondary to 
pneumonia or pleurisy, is usually due to the pneumococcus. In other cases 
any of the pyogenic germs may be found. 

6. Pericarditis with an effusion of blood is very rare in children. It 
may occur from the rupture of organized adhesions or in certain blood 
states such as purpura, and very rarely in tuberculosis. 

Pericarditis complicating pneumonia and pleurisy is generally fibrinous 
or fibrino-purulent ; that with rheumatism is sero-fibrinous, and often 
accompanied by endocarditis. With acute tuberculosis there is usually 



PERICARDITIS. r , 71 

only a deposit of miliary tubercles, or there may be a small serous or sero- 
sanguinolent effusion. In chronic cases there may be a tuberculous in- 
flammation with the formation of caseous nodules, new connective tissue, 
and extensive adhesions. This generally occurs in connection with pul- 
monary tuberculosis — sometimes with tuberculous peritonitis. 

In any form of pericarditis complete recovery, so far as pathological 
conditions are concerned, is rare — if, indeed, it ever occurs. Generally 
adhesions remain, which may be in the form of a few thin connective- 
tissue bands, or so extensive as to produce almost entire obliteration of 
the pericardial sac. Such adhesions are usually followed bv secondary 
changes. The growth and development of the heart are interfered with, 
and there may be sufficient pressure upon the coronary vessels to lead to 
degeneration of the muscular walls and dilatation of the heart. With 
large fluid exudations there maybe an interference with the systemic circu- 
lation, enlargement of the spleen and liver, and sometimes general dropsy. 

Symptoms. — A pericardial transudation, or dropsy of the pericardium, 
is very rarely large enough to make a diagnosis possible. 

External pericarditis is seldom recognised during life, there being no 
symptoms except those of the pleurisy with which it is associated. Occa- 
sionally there may be heard, particularly if the inflammation is anterior, 
a pleuritic friction sound which is increased with the systole of the heart. 
The pulse may be weak during inspiration, and there may be an increased 
area of cardiac dulness. If the inflammation is chiefly posterior, it causes 
only the symptoms of mediastinitis, which is recognised principally by its 
pressure effects upon the great vessels. It may produce oedema of the 
face or of the lower extremities, ascites, enlargement of the liver and 
spleen, but rarely albuminuria. It lasts from a few months to two 01 
three years, according to its cause. 

Inflammation of the internal layer is the only form usually described 
as pericarditis. This is very frequently overlooked, not only on account 
of its rarity, but from the obscurity of its symptoms. The difficulty in 
diagnosis is particularly great in young children. The symptoms are few, 
and many of them are equivocal. As this disease is nearly always second- 
ary, the physician should be on the watch for it in infants with pleurisy 
or pleuro-pneumonia of the left side, atid in older children in the course 
of articular rheumatism. Localized pain and tenderness may be pn 
and also a certain amount of embarrassment of the heart's action, usually 
manifested by pra3cordial distress, palpitation, and slight irregularity 
the pulse. There may be dyspnoea, and if there is a large eflfnsion pn 
there may be orthopno-a and cyanosis. Sometimes there ifi delirium. 
When pericarditis follows pleurisy <>r pleuro-pneumonia there are fre- 
quently no new symptoms added. 

The physical signs in older children resemble those in adults. In dry 
pericarditis there is usually heard a double friction sound 0?er th< 



572 DISEASES OF THE CIRCULATORY SYSTEM. 

dial space, the area being generally small and near the base of the heart. 
The sound is not transmitted, and bears no relation to the respiratory 
movements. After effusion has taken place the apex beat may be dis- 
placed upward, diffused, and somewhat indistinct, or it may not be found 
at all. There may be bulging of the chest wall. On palpation, there is an 
absence of vocal fremitus over an area usually occupied by the lung. Per- 
cussion gives an area of marked dulness or flatness of triangular shape, 
the base being below and the apex above. The normal area of cardiac 
dulness is increased in all directions, and this dulness extends beyond the 
limits of the heart. On auscultation, the heart sounds are feeble and dis- 
tant. Friction sounds disappear as serum is poured out, and reappear as 
it is absorbed. Endocardial murmurs may also be present. In infants, 
physical signs are often entirely wanting, or the normal sounds may be 
feeble, distant, or absent. 

The usual duration of acute pericarditis is from one to three weeks. 
The ordinary dry form, with its resulting adhesions, may be followed by a 
subacute or chronic form of the disease. In the sero-fibrinous form the 
serum is usually absorbed quite promptly, and only adhesions are left, or 
a chronic inflammation follows, with exacerbations in each recurrence 
of rheumatism. In the purulent form of the disease in young children, 
death is the most frequent termination. If the pus is evacuated, or spon- 
taneous opening takes place, there may be recovery, but always with more 
or less extensive adhesions remaining. 

Prognosis. — Of thirty-five cases in Steffen's collection, only six recov- 
ered. This statement is to be taken rather as evidence of the great difficulty 
of diagnosis than of a very high mortality, although the disease is always 
a serious one. The prognosis depends chiefly upon the exciting cause. 
When due to pyaemia or the acute infectious diseases, or when extending 
from pleurisy or pneumonia, the prognosis is bad. Here it is usually the 
primary disease rather than the pericarditis which is the cause of death ; 
the latter may be the case, however, if the effusion is large. The cases in 
which the pericarditis itself is the most important disease are those de- 
pending upon rheumatism. Although immediate danger to life may not 
often be great, yet convalescence is slow, and the remote consequences of 
the disease, by reason of adhesions, may be very serious. 

Diagnosis. — Owing to the very rapid action of the heart in children, 
acute dry pericarditis presents difficulties of diagnosis in early life which 
are not present in the adult. The disease is fortunately so rare under 
three years, that in ordinary practice it need seldom be considered. In 
older children the diagnosis is to be made by essentially the same signs as 
in adults. Pericarditis with effusion is to be diagnosticated from dilata- 
tion of the heart and from pleuritic effusions. From dilatation, the diag- 
nosis is not often difficult in childhood, for this is not a common con- 
dition, and is rarely extreme except in advanced valvular disease. From 



CHRONIC PERICARDITIS WITH ADHESIONS. 573 

pleuritic effusions the diagnosis is at times almost impossible. Signs 
pointing to a sacculated empyema of the left side anteriorly should always 
be regarded with suspicion, particularly if the apex beat is not displaced 
to the right, and if the heart sounds are very feeble. When empyema and 
pericarditis coexist, it may be impossible to recognise the condition. The 
diagnosis between serous and purulent effusions can be made only by aspi- 
ration. Fluid effusions in infants are almost invariably purulent, and bo 
also are they in the majority of cases in older children, unless due to rheu- 
matism. 

Treatment. — In the early part of an attack of acute pericarditis the 
patient should be kept in bed and as quiet as possible, and hot poultices or 
counter-irritation bv mustard used over the heart. Sometimes an ice bas 
may with advantage be substituted. Excessive heart action may be con- 
trolled by aconite, and severe pain may require opium. If the disease is 
due to rheumatism, anti-rheumatic remedies should be employed. Serous 
effusions usually subside under simple tonic treatment. If absorption is 
slow, it may be hastened by counter-irritation. "When a large effusion 
forms rapidly there maybe danger of death from syncope. Symptoms 
which indicate an unfavourable termination are cyanosis, weak, irregular 
pulse, and great dyspnoea, or orthopncea. Under these conditions aspiration 
may afford temporary relief, and free diuresis should be induced by citrate 
of potash and caffein. The inhalation of oxygen is at times of greal value 
in cases presenting such urgent symptoms. If pus is shown to be presenl 
by puncture, incision and drainage should be practised, as in empyema. 
The results of aspiration in such cases are extremely unfavourable. Of 
eighteen cases of aspiration of the pericardium collected by Keating, only 
four recovered. In puncturing the pericardium the point usually selected 
is a little to the left of the border of the sternum in the fifth intercostal 
space, the needle being directed upward and outward. 

CHRONIC PERICARDITIS WITH ADHESIONS. 

This is not a very uncommon condition. It mav be general or local- 
ized. The youngest case which has come under my observation was m a 
female child sixteen months old, who died from acute broncho-pneumonia. 
The adhesions w r ere old and general, the pericardial sac being completely 
obliterated. There was also some old pleurisy present. The hist 
threw no light upon the lesions. As already Btated, such adhesions • 
follow single, but more frequently recurrent, attacks of rheumatic p< 
carditis. Sometimes the process may be tuberculous. The adhesions maj 
increase until they are one eighth or even one fourth of an inch in thick- 
ness. Adhesive pericarditis is usually accompanied by some dilatation of 
the heart, which may be preceded by hypertrophy, and then- maj or maj 
not be valvular disease. 

Partial adhesions cause no symptoms by which they ''an 



574 DISEASES OF THE CIRCULATORY SYSTEM. 

and even general adhesions sufficient to obliterate the pericardial sac are 
found at autopsy where not suspected during life. This is one of the 
conditions in which, after it has led to considerable dilatation of the 
heart, sudden death sometimes occurs. It often happens that the only- 
cardiac symptoms present are such as could be explained by functional 
disturbance. The heart is almost invariably enlarged. On inspection, 
there is seen bulging of the chest wall, with a strong and somewhat dif- 
fused apex beat. One of the most characteristic signs is that during sys- 
tole there occurs a retraction of the chest over a small area at or near the 
apex of the heart, sometimes at the tip of the sternum, and sometimes at 
the epigastrium. This is often better appreciated by palpation than by 
inspection. It is followed by a rapid rebound, associated with diastolic 
collapse of the jugular veins. A similar retraction, according to Broad- 
bent, is to be seen behind in the infrascapular region, sometimes on the left 
and sometimes on the right side. Percussion shows an increase in the car- 
diac dulness in all directions, but particularly upward. Hale White has 
called attention to the frequency of a presystolic murmur of a " blubber- 
ing" character in these cases. The diagnosis of adherent pericardium 
always presents difficulties, but it can be made with tolerable certainty in 
a considerable proportion of the cases. On account of the enlargement 
of the heart and the frequency of the murmurs, it is usually mistaken for 
valvular disease. The lesion is a permanent one, and tends to increase. 
The treatment is symptomatic. 



CHAPTER IV. 
ENDOCARDITIS AND VALVULAR DISEASE. 

ACUTE SIMPLE ENDOCARDITIS. 

Acute endocarditis may occur even in foetal life. At this period it 
usually affects the right side of the heart, and is one of the important 
causes of congenital malformations. In infancy, acute endocarditis is 
exceedingly rare, not a single instance being found in over one thousand 
autopsies upon children under three years of age of which I have records. 
From the third to the fifth year it is not so rare, and after this period it 
is quite common. Of 95 cases observed by Steffen, 15 occurred before 
the sixth year, and 80 between the sixth and fourteenth years. 

Acute endocarditis may be primary, but it is much more frequently a 
secondary disease. The primary cases have been the subject of much dis- 
cussion, but I agree with those who regard the great majority of these 
as rheumatic. Cheadle (London) has well said that we are to look 
upon endocarditis in children not as a complication of rheumatism, so 



ACUTE SIMPLE ENDOCARDITIS. 575 

much as a manifestation — often the first — of that disease. Sometimes 
endocarditis occurs alone, and sometimes it is associated with chorea with- 
out articular symptoms ; but the latter almost invariably appear sooner or 
later. Endocarditis is seen as a frequent complication both of acute and 
of subacute articular rheumatism. The proportion of rheumatic cases in 
which it occurs is much larger in children than in adults. Compared 
with rheumatism, all other causes of acute endocarditis are very infre- 
quent. It is seen occasionally in the course of nearly all the acute infec- 
tious diseases, most often with scarlet fever, and it sometimes complicates 
•pleurisy and pneumonia, being usually associated with pericarditis. In 
infectious diseases, and in pleurisy and pneumonia, the endocarditis is 
probably excited by pathogenic germs. Fraenkel and Sanger have found 
the staphylococcus in cases of simple endocarditis, and cultures by others 
have shown the presence of other pyogenic organisms, including the 
pneumococcus. 

Lesions. — Acute inflammation may affect any part of the endocardium, 
but in extra-uterine life it usually affects the valves of the left side, involv- 
ing the mitral much more frequently than the aortic valve. Steffen's 
figures give only four examples of aortic disease in ninety-five cases. 
(Compare statistics of valvular disease, page 583.) 

The pathological changes consist first in an extensive growth of new 
connective-tissue cells and an infiltration of round cells beneath the endo- 
thelial layer. This results in the formation of small masses of granulation- 
tissue upon the valves or the endocardium of the heart wall, and upon 
these there is deposited fibrin from the blood. In this way the tiny wart- 
like excrescences known as vegetations are produced. Bacteria may also 
be caught in the exudate. As a consequence of the inflammation, the valve 
is swollen, somewhat shortened, and consequently insufficient. The results 
of the process maybe ulceration of this new-formed tissue, which in ordi- 
nary cases is small in amount, or organization and cicatrization. Ma 
of fibrin may be detached from the vegetations and swept into the general 
circulation, lodging as emboli in the kidneys, spleen, brain, or other 
organs. This is not common in acute endocarditis, at least Dot in the 
first attacks. 

In the milder forms of inflammation it is possible for complete n 
ery to take place, with the exception of a slight valvular thickening, do! 
enough, however, to interfere in any way with the function of the va 
But this result is rare. In most oases they remain Blightly insufficiei I 
the least serious consequence of the inflammation, Unfortunately, it more 
often happens that an acute inflammation which may not be at first 
ous, proves the beginning of the progressive changes of a chronic inflam- 
mation, the full effects of which are not seen for years. Chronic inflam- 
mation may follow the first attack immediately, or after a considerable 
interval, or occur after several acute attacks. 



576 DISEASES OF THE CIRCULATORY SYSTEM. 

Symptoms. — When acute endocarditis occurs as a primary disease, or 
when it is the only manifestation of rheumatism, it usually begins abruptly 
with rather severe general symptoms — high temperature, often 102° to 
105° F., prostration, exaggerated heart action, restlessness, and some- 
times dyspnoea. There is nothing distinctive about these symptoms, and 
it is not until the heart is examined that the disease is recognised. If the 
heart is not watched, the diagnosis is not made, and there may be no sus- 
picion of the nature of the attack until some time afterward, when the 
existence of valvular disease is discovered. If the heart is carefully 
examined from day to day, nothing abnormal may be found until the third 
or fourth day, or even later, when there is heard the characteristic soft, 
blowing, systolic murmur at the apex. The murmur is generally trans- 
mitted to the left. It may be accompanied by a thrill and by an accentu- 
ated pulmonic second sound, and later there may be evidence of slight dila- 
tation with the usual signs of some degree of cardiac insufficiency. The 
murmur gradually increases in intensity until the maximum is reached, 
and then in most cases somewhat subsides. 

Acute endocarditis sometimes occurs in the course of, or simultane- 
ously with, an attack of chorea, with symptoms quite similar to those 
described. Finlayson (Glasgow) has called attention to endocarditis as 
a frequent cause of obscure fever in choreic patients, either when occur- 
ring alone or with articular symptoms. It may develop at any time 
during the choreic attack or subsequent to it. When endocarditis occurs 
as a complication of articular rheumatism, there may be an increase in the 
temperature and in the severity of the general symptoms, but rarely any- 
thing more definite. Endocarditis complicating other diseases is recog- 
nised only by the physical signs. 

The usual duration of acute endocarditis is from one to three weeks, 
the febrile symptoms frequently subsiding in a few days and the cardiac 
symptoms slowly diminishing. 

The attack may terminate fatally in the course of a few weeks, owing 
to the rapid development of acute dilatation, accompanied by the usual 
signs of cardiac insufficiency, with dropsy, cyanosis, and often pulmonary 
complications. Cerebral embolism may occur, which usually produces 
hemiplegia, but rarely results fatally. If emboli lodge in the spleen or 
kidneys, they may lead to swelling of the spleen or to hematuria. The 
patient may recover with a murmur which lasts but a few weeks and 
gradually disappears — a rare result. Usually there is a persistent mur- 
mur, with the subsequent development of the ordinary signs of valvular 
disease. Lastly, there may be recurrent attacks of inflammation, with the 
ultimate development of chronic valvular disease. 

Diagnosis. — The diagnosis of acute endocarditis is very frequently not 
made ; not because it is difficult, but because in young children the heart 
is not examined as frequently and as carefully as it should be. The symp- 



ACUTE SIMPLE ENDOCARDITIS. ;,;; 

toms are few and not diagnostic. It is therefore of the greatest impor- 
tance that not only in chorea and rheumatism, but in all acute febrile 
attacks, particularly those of obscure origin, the heart should be closely 
watched. Endocarditis affecting the wall of the heart can not be diag- 
nosticated. The murmur of valvular endocarditis may be confounded with 
pericarditis, or with functional or blood murmurs occurring in the course of 
acute febrile attacks, or with those of anaemic origin. From pericarditis it 
is distinguished by the fact that the murmur is single, has a soft blowing 
character, is usually located at the apex, is transmitted beyond the bor- 
der of the heart, and is diminished by a full inspiration. Functional 
murmurs in febrile diseases are quite frequent in young children, and 
may at first be difficult to distinguish from those of endocarditis. Usually, 
however, the former are at the base rather than at the apex. They are 
more irregular, both as to time, transmission, and constancy, than are mur- 
murs resulting from acute endocarditis. The same may be said of amende 
murmurs, which, as in adults, may be heard in the carotids, and some- 
times over any of the large arteries. 

Prognosis. — The danger to life in acute endocarditis is not often great, 
as the disease seldom proves fatal. However, death may occur when it is 
associated with chorea, but here usually when an acute process is ingrafted 
upon an old valvular disease. In other cases, death results from compli- 
cations, particularly pneumonia. Only the progress of the case enables 
one to decide how extensive is the damage which has been done to the 
valves. There is always the danger of recurrent attacks. 

Treatment— All the so-called primary cases, as well as those occurring 
with chorea and articular symptoms, should have the benefit of anti- 
rheumatic remedies, as this is the only plan which offers any chance of 
limiting the inflammation, although the effect upon the heart is rarely 
striking. Excessive cardiac action is sometimes allayed by aconite, 
sometimes best by opium. The most important thing in the manageo 
of these cases, and the one frequently overlooked, is to Becure for the heart 
as complete rest as possible, not only during the period of acute inflam- 
mation, but for several succeeding weeks. Patients should be kept ir 
for at least a month, and only the slightest exertion permitted for many 
weeks. It is during this early period of the disease that changes take 
place most rapidly in the heart walls, and the graves! result* 
follow the neglect of these precautions. Children are often allowed out of 
bed as soon as the fever has subsided, and the heart disease is annot 
until a grave amount of dilatation has developed, with dropsy, palpitation, 
shortness of breath, slight cyanosis, irregular pulse, and oougl 
dren who have once suffered from endocarditis should be prd 
much as possible against subsequent attacks of rheuD 



44 



578 DISEASES OF THE CIRCULATORY SYSTEM. 



MALIGNANT ENDOCARDITIS. 

Malignant or ulcerative endocarditis is a rare disease in childhood. 
The youngest case I have found reported is that of Harris, which occurred 
in a boy four years old, and affected the right side of the heart. It was 
secondary to a cardiac malformation. Of the cases thus far reported in 
early life, about twenty-five in number, the great proportion have been in 
children over ten years of age, in whom the disease does not differ essen- 
tially from the adult type. For the most exhaustive study of this subject 
we are indebted to Osier's G-ulstonian Lectures. 

Malignant endocarditis rarely occurs as a primary affection. Of the 
acute diseases, it is most frequently secondary to pneumonia, next to 
rheumatism and meningitis. It may be met with in any infectious dis- 
ease or septic process. In 75 per cent of the cases, according to Osier, it 
is ingrafted upon a previous valvular disease. In my series of collected 
cases of congenital malformations of the heart, there were four deaths 
from malignant endocarditis, all but one, however, occurring in adult life. 

The bacteria most frequently associated are the staphylococcus and 
streptococcus, and, in the cases complicating pneumonia, the pneumococ- 
cus. These micro-organisms are believed to play an important part in the 
production of the disease. Circulating in the blood, they lodge upon the 
endocardium of the valves, all the more readily when they are previously 
diseased. 

Lesions. — Malignant endocarditis may result in the production of vege- 
tations which subsequently break down, or there may be superficial ulcera- 
tion affecting only the endocardium, or deeper ulceration involving the 
valve, the septum, or even the heart wall. In other cases there is suppura- 
tion of the deeper tissues of the valve first affected, with the production of 
small abscesses at the base of the vegetations. These conditions may lead 
to large perforations, or even to the destruction of the valve, to valvular 
aneurisms, or abscesses of the heart wall. According to Osier, the differ- 
ent parts of the heart are affected in the following order : mitral valve ; 
aortic, mitral and aortic combined ; tricuspid and pulmonic valves ; and 
the cardiac wall. The secondary lesions of malignant endocarditis are due 
to emboli. These are most frequent in the spleen and kidney, next in 
the brain, intestines, and skin, and, if the right side of the heart is dis- 
eased, in the lungs. These emboli lead to the formation of red or white 
infarctions, to haemorrhages, or to multiple abscesses in the various organs 
and tissues in which they lodge. 

Symptoms. — Malignant endocarditis presents a great variety of symp- 
toms, making the diagnosis extremely difficult in perhaps the majority of 
cases. There is generally a remittent type of fever, sometimes repeated 
rigors, profuse sweating, low delirium, stupor or coma, and extreme pros- 
tration. In many cases there is a fine petechial eruption upon the skin ; 



CHRONIC VALVULAR DISEASE. 579 

diarrhoea is also frequent. The cerebral symptoms may be so prominent 
as to suggest meningitis. There is usually a cardiac murmur, the location 
of which depends upon the seat of disease. It is most frequently the 
murmur of mitral regurgitation. This murmur is sometimes faint, and 
may be absent. The spleen is in most cases enlarged. From the emboli 
there may be hemiplegia, rapid swelling of the spleen, bloody urine, cough, 
and symptoms of pneumonia. The disease lasts from a few days to six 
weeks, death being the almost invariable termination. It is due to ex- 
haustion or to some embolic process. 

Diagnosis. — The most characteristic features of malignant endocarditis 
are the development of pysemic or typhoid symptoms with a petechial 
eruption, in a patient who has previously had valvular disease. Malignant 
endocarditis is differentiated from typhoid fever by its sudden onset, 
irregular temperature, recuiring chills, profuse sweats, petechial eruption, 
and dyspnoea. It may be confounded with malarial fever. 

Treatment. — This is entirely symptomatic ; no knowu measures have 
any influence upon the disease itself. 

CHROXIC VALVULAR DISEASE. 

Chronic valvular disease of the heart in children is usually the result 
of endocarditis ; in a small number of cases it depends upon congenital 
malformation ; but the degenerative lesions to which many adult cases are 
due have no place in early life. 

Lesions. — The changes of chronic endocarditis may be briefly described 
as follows : The valvular segments are thickened by the production of new 
connective tissue, the contraction of which results in retraction, shorten- 
ing, puckering, and imperfect closure of the valves. The valvular leaflets 
may adhere to each other, so that the opening i> very much narrowed. 
This is sometimes reduced to a funnel-shaped orifice barely admitting the 
tip of the finger, and it may even be much smaller. The leaflets are some- 
times adherent to the wall of the heart; the chorda' tendinse are short- 
ened, and sometimes entirely disappear ; and, finally, the valves may Ik- the 
seat of calcareous deposits. These changes take place very Blowly, requir- 
ing many years for their full development From time t<» time there may 
be attacks of acute inflammation. The changes described may bring b 
(1) valvular insufficiency, owing t<» imperfect closure, causing cita- 

tion of blood through the opening guarded by the valve: oi 
with such a narrowing of the opening that the flow of blood is obstructed 
In early life it is usually the mitral valve that is affected. 

Of 141 cases in children under fourteen years old, observed clinically by 
Dr. F. M. Crandall and myself, the mitral valve was alone affi 
cent; the aortic valve alone in :) percent; and both wen- ted in 

18 per cent. Lesions of the aortic valve in early life are therefore 1 
paratively rare. 



580 



DISEASES OF THE CIRCULATORY SYSTEM. 



Following valvular lesions, important changes take place in the wall 
and cavities of the heart : these are hypertrophy and dilatation. 

Hypertrophy. — This consists in an increase in the thickness of the 
heart wall, due to an increase in the size and number of the muscular 
fibres. It is principally of the ventricles, and is always conservative. It 
may continue indefinitely, or it may be followed by degeneration and dila- 
tation. Hypertrophy occurs as a result of any obstructive lesion at one of 
the cardiac orifices, in renal disease when the obstruction is in the small 
arteries, also when extra work is thrown upon the ventricles as a result of 
regurgitation, and it may follow primary dilatation. 

Dilatation. — This consists in an enlargement of the cavities of the 
heart, usually with thinning of their walls. It is generally most marked 
in the auricles. Primary dilatation is produced by regurgitation of blood 
into any of the cavities as a result of valvular insufficiency. This may to 
a slight extent be regarded as a conservative lesion. Secondary dilatation, 
or that resulting from degeneration of the cardiac muscle, is always in- 
jurious. It is usually caused by imperfect nutrition of the heart which 
may be due to local or general causes. In most of the cases both hyper- 
trophy and dilatation continue for a long time. So long as hypertrophy 
predominates, the circulation may be well carried on ; but when dilatation 
comes to exceed hypertrophy, there are signs of great embarrassment to 
the circulation and of cardiac insufficiency. 

There are other lesions accompanying chronic valvular disease, de- 
pending upon obstruction to the venous circulation. If this obstruction 
is in the pulmonary veins, it leads to congestion of the lungs, chronic 
bronchitis, or chronic pneumonia ; if of the systemic venous circulation, 
it leads to chronic congestion of the spleen, liver, kidneys, peritonaeum, 
and sometimes to general dropsy. 

Etiology. — The following table gives the age and sex in the cases ob- 
served by Dr. Orandall and myself : 





1 

year. 


2 
years. 


3 

years. 


4 

years. 


5 

years. 


6 
years. 


7 
years. 


8 
years. 


9 
years. 


10 
years. 


ii 

years. 


12 
years. 


13 

years. 


14 

years. 




Males 

Females. . . 




1 
1 


2 
3 


2 
5 


4 

7 


6 
9 


4 
10 


9 
3 


8 
11 


6 
12 


5 
14 


7 
4 


6 

2 


1 

3 


= 55, or 38$ 
= 90, " Q2% 


Total.... 




2 


5 


7 


11 


15 


14 


12 


19 


18 


19 


11 


8 


4 


= 145 



The difference in sex is very nearly the same as was found in my cases 
of rheumatism. Sturges, in 100 cases, gives 56 per cent females and 44 
per cent males. Sansom's figures alone give a predominance of males. 

The chronic endocarditis of early life is, as a rule, secondary to the 
acute or subacute form. Its etiological factors are therefore those of 
acute endocarditis. Of 117 cases in my own series, 93, or 80 per cent, 
gave a history of previous rheumatism — 7 cases of chorea without ar- 
ticular symptoms being included as rheumatic. Of the 31 cases which 



CHRONIC VALVULAR DISEASE. 5S1 

at the first examination gave no history of rheumatism, 8 subsequently 
developed articular rheumatism, and 2 chorea, so that nearly 90 per cent 
of this series of cases presented, to my mind, conclusive evidence of a 
rheumatic diathesis. Thirty per cent had chorea previously, or developed 
it while under observation. The more closely I study cases of rheumatism, 
chorea, and valvular disease, and the longer the patients are kept under 
observation, the deeper becomes my conviction of the very close relation- 
ship between these three conditions in childhood. The percentage of 
rheumatic cases in this series is considerably larger than that given by 
many writers, but it corresponds very closely with Cheadle's careful obser- 
vations. Valvular disease is occasionally traced to an attack of endo- 
carditis complicating scarlet fever, and in rare cases to that occurring with 
other infectious diseases. 

Symptoms. — The symptoms of chronic valvular disease in most cases 
come on slowly, often insidiously, and frequently there are none until the 
disease has lasted a long time, the condition being discovered by accident. 
The course of valvular disease is usually divided into two periods, the first 
being that while compensation is present, and the second after compensa- 
tion has failed. The duration of the stage of compensation is indefinite ; 
it may last a lifetime. The only subjective symptom that is of much diag- 
nostic value is shortness of breath on exertion. Occasionally other symp- 
toms are present, such as precordial pain, attacks of palpitation, head- 
ache, epistaxis, anaemia, and cough. These are rarely constant, but come 
on when the patient's general condition for any reason is below normal. 
As a rule, there is in young subjects a tendency to an increase in the dis- 
ease, although this is often slow, and may be interrupted by long periods 
in which the process appears to be stationary. At such times the patients 
either have no symptoms, or suffer only from a slight amount of incon- 
venience on marked exertion. 

Failure in compensation is generally brought about by one of the fol- 
lowing causes: There maybe an intercurrent attack of acute endocarditis, 
which in a short time leads to a very great increase in the heart's disability. 
It may be due to additional work thrown upon the heart from. 
muscular exertion, or to the strain of a prolonged attack of Borne acute ill- 
ness, especially one that is liable to produce changes in the hear! muscle, 
such as typhoid or scarlet fever. It is sometimes tie- increased work which 
is physiologically thrown upon the heart at the time of puberty, owil 
the rapid growth of the body. It may resull from any cause whirl! 
ously affects the patient's general nutrition, particularly when tl 
associated with marked anaemia. 

The symptoms indicating failure of compensation are those depending 
upon a weak heart, with imperfeel filling of the arteries and overfillii 
the veins. The embarrassment of the pulmonary circulation lead 
stant dyspnoea or orthopncea and cough, sometimes accompanied I • 



582 DISEASES OF THE CIKCULATORY SYSTEM. 

expectoration, which may be bloody, and in rare cases there may be larger 
pulmonary haemorrhages. The obstruction to the systemic venous circu- 
lation leads to dropsy, which begins in the feet. There may be general 
anasarca and dropsy of the serous cavities, especially the peritonaeum and 
pleura ; also enlargement and functional disturbances of the liver, en- 
largement of the spleen, dyspeptic symptoms, and chronic congestion of 
the kidney, with scanty urine and albuminuria. There may be dilatation 
of the superficial veins, with clubbing of the fingers, and cyanosis ; and 
there may be cerebral symptoms, such as headache, dizziness, and faint- 
ing attacks. The pulse is small and soft, and the heart's action rapid 
and irregular. 

It is rare to see all the symptoms of cardiac failure in children 
under ten years, but about the time of puberty they are not uncommon. 
The symptoms may increase in severity until death occurs, or they may 
be severe for a time and then nearly disappear, to return again after a 
longer or shorter interval.* Death may be due to sudden cardiac paralysis, 



* The course and termination of these cases of chronic valvular disease is well 
illustrated by the following history of a little girl who was under observation for 
nine years : When first seen she was seven years old, and gave a history of cardiac 
symptoms for one year. There was then present a loud mitral regurgitant murmur, 
with considerable hypertrophy. There was general dropsy, and all the symptoms 
pointed toward acute dilatation. Under treatment, the dropsy and other symptoms 
disappeared, and she went on comfortably for over a year. In her eighth and ninth 
years there were frequent attacks of subacute rheumatism, during which time the 
heart lesion steadily increased in severity. At twelve years there was an eruption of 
subcutaneous tendinous nodules, which remained for over two years. During this 
year there was heard for the first time a mitral direct murmur, accompanied by a very 
marked thrill, mitral stenosis having been gradually brought about by the slowly pro- 
gressing endocarditis. This murmur gradually increased in intensity from that time, 
while the mitral regurgitant murmur became less distinct. The apex beat at this time 
was in the sixth space, two and a half inches to the left of the nipple. From the 
twelfth to the fifteenth year she grew very little in height or weight, and showed no 
signs of maturity, the cardiac symptoms being nearly stationary. In the fifteenth, 
year she developed a marked enlargement of the liver and spleen with general dropsy 
and all the symptoms of cardiac insufficiency, these being the first symptoms of this 
character since she was seven years old. There was now heard for the first time an 
aortic regurgitant murmur in addition to the others formerly present. The symptoms 
disappeared under treatment in the course of a few months, but six months later re- 
turned with greater severity and were accompanied by albuminuria, the patient dying 
from heart failure in a few weeks. During the last exacerbation there was heard a 
double aortic as well as a double mitral murmur. 

At autopsy the heart weighed fifteen ounces. There was a very great hypertrophy, 
especially of the right ventricle, which was as thick as the left. All the cavities were 
much dilated. The most important valvular lesion was mitral stenosis, the orifice not 
admitting the end of the little finger. The valves were the seat of calcareous deposit. 
The curtains of the aortic valve were thickened and adherent ; there was also thicken- 
ing of the pulmonic and tricuspid valves. 



CHRONIC VALVULAR DISEASE. 



583 



to intercurrent nephritis, pneumonia, embolism, inflammation of the se- 
rous membranes, or to oedema of the lungs. 

Clinical Varieties.— Of the 141 cases of valvular disease in children 
under fourteen years, previously referred to, the following were the forms 
and combinations recorded. It is to be noted that these figures are based 
upon clinical and not pathological examinations : 



Mitral insufficiency 131 cases ; alone in 90 cases. 

Mitral stenosis ...... 17 " " " 4 

Aortic insufficiency 9 " " " " 

Aortic stenosis 28 " " " 3 " 

Double mitral 8 " 

Double aortic 1 case. 

Double mitral and double aortic 3 cases. 

Mitral insufficiency and double aortic 3 " 

Mitral insufficiency and aortic stenosis 18 " 

Mitral stenosis and aortic insufficiency 2 " 

Mitral insufficiency. — This is usually the result of attacks of acute 
endocarditis. It is by far the most frequent form of valvular disease in 
early life, occurring in 93 per cent of the above cases, and alone in 70 per 
cent. In mitral insufficiency there is regurgitation of blood from the left 
ventricle into the left auricle during systole. This is compensated for by 
hypertrophy of both ventricles. It causes dilatation of the left auricle, 
increased, pressure in the pulmonary veins, afterward in the pulmonary 
arteries, hypertrophy of the right ventricle, and, finally, there is dilata- 
tion of the right ventricle, tricuspid insufficiency, dilatation of the right 
auricle, and general systemic venous obstruction. Coincident with the 
changes in the right heart there is hypertrophy of the left ventricle, fol- 
lowed by dilatation. 

In mitral insufficiency there is heard a systolic murmur which ifl syn- 
chronous with the apex impulse and with the first sound of the heart, and 
may in part replace the first sound. It is loudest at the apex, trans- 
mitted to the left, and heard with almost equal distinctness at the inferior 
angle of the left scapula. This is a very diffusible murmur, and may be 
audible all over the chest. It is accompanied by an accentuation of the 
pulmonic second sound heard at the left border of the Bternum in the 
second space, and by signs of hypertrophy of the heart. Wnen both these 
signs are wanting, the existence of mitral insufficiencj is somewhat doubt- 
ful, as a similar murmur may be of functional or accidental origin. In 
the early stages of the disease the signs of hypertrophy predominate j in 
the later stages, those of dilatation. 

In hypertrophy of the left ventricle or of the whole heart, the 
beat is displaced downward and to the left.* It may be in the fifth or 



* For normal position ot the apes in chil 



584 DISEASES OF THE CIRCULATORY SYSTEM. 

the sixth space, but rarely lower, and as far to the left as the axillary line. 
There is often bulging of the praecordia, so marked as to cause a deformity 
of the chest. The impulse is forcible and heaving, and over a larger space 
than normal. The area of cardiac dulness is increased in all directions, 
but particularly downward and to the left. In hypertrophy involving 
chiefly the right ventricle, there may be bulging of the lower part of the 
sternum, and the area of dulness is increased to the right, in extreme cases 
extending from one to one and a half inches beyond the right border of the 
sternum. The heart sounds in hypertrophy are loud and distinct, and 
often have a somewhat metallic character. With hypertrophy of the right 
ventricle there may be reduplication or accentuation of the second sound. 
The pulse is full and strong. 

In dilatation the apex beat is indistinct, diffuse, and undulatory. 
There is an increase in the area of cardiac dulness, the outline being nearly 
square. The cardiac sounds are feeble, and murmurs previously present 
may be lost. The heart's action is irregular, and the pulse small and 
weak. 

Mitral stenosis. — This is apt to occur from repeated attacks of subacute 
rheumatism, with a slowly progressing endocarditis. It is usually asso- 
ciated with mitral regurgitation, but may occur alone. There is with this 
lesion obstruction to the flow of blood from the left auricle into the left 
ventricle. It is mainly compensated for by hypertrophy of the right ven- 
tricle, but to a certain degree by hypertrophy of the left auricle. The 
secondary changes following the lesion are hypertrophy of the left auricle 
followed by dilatation, increased pressure in the j)ulmonary veins, followed 
by hypertrophy and dilatation of the right ventricle. The left ventricle 
is usually normal or small. 

Mitral stenosis produces a presystolic murmur which is somewhat 
prolonged, usually rough in character, and terminates sharply with the 
first sound of the heart. It is loudest at or near the apex, but is audible 
over only a small circumscribed area. Quite as constant and important 
for diagnosis is the presence of a " purring thrill," which is very distinct 
upon palpation, and terminates sharply as the apex strikes the chest wall. 
The pulse of mitral obstruction is usually small. The symptoms are few, 
but those which are present depend chiefly upon pulmonary congestion. 

Aortic stenosis. — This is not very common in early life, and rarely 
occurs as the only murmur, being most frequently associated with mitral 
insufficiency. It is sometimes a congenital murmur. Aortic obstruction 
is compensated for by hypertrophy of the left ventricle, which may be 
complete for a long period, but ultimately it is followed by dilata- 
tion of the left ventricle, with mitral insufficiency and its consequences. 
In aortic obstruction there is an interference with the outflow of blood 
from the left ventricle into the aorta. It causes a systolic murmur, which 
is usually loudest at the right border of the sternum in the second space, 



CHRONIC VALVULAR DISEASE. 5S5 

and is transmitted upward, being distinct in the carotids. The second 
sound is generally weak. There are associated the signs of marked hyper- 
trophy of the left ventricle. 

Aortic obstruction is more frequently confounded with conditions giv- 
ing accidental or functional murmurs than is any other valvular lesion. 
Without the signs of hypertrophy of the left ventricle, a positive diagnosis 
should not be made. On account of the almost perfect compensation, 
this form of the disease causes fewer symptoms than any other variety, 
possibly excepting mitral obstruction. The danger of embolism is some- 
what greater than in mitral disease. 

Aortic insufficiency. — This is one of the rarest valvular lesions in chil- 
dren. In no case on my list did it occur as the only lesion. It causes a 
regurgitation of blood from the aorta into the left ventricle during dias- 
tole. It is compensated for by dilatation and hypertrophy of the left 
ventricle. The order in which the secondary changes take place is : dila- 
tation followed by hypertrophy of the left ventricle, ultimately followed 
by further dilatation due to degeneration, this leading to mitral insuffi- 
ciency with all its remote consequences. The signs of aortic insufficiency 
are a prolonged diastolic murmur, with, or taking the place of, the second 
sound of the heart, generally loudest at the left border of the sternum in 
the second space, and transmitted downward to the apex of the heart or the 
ensiform cartilage. This is invariably accompanied by signs of hyper- 
trophy and dilatation of the left ventricle, these being usually marked 
In the stage of compensation the signs of hypertrophy predominate, and 
when compensation has failed, the signs of dilatation. A characteristic 
symptom is the intense throbbing of the carotids, with the sudden disten- 
sion and complete collapse of their walls, and the "ball-pulse" of Oorri- 
gan. Early in the disease there may be headache, flashes of light before 
the eyes, and other evidences of cerebral congestion. In the 1. 
there may be fainting attacks. With this lesion compensation may be 
complete for a long time. 

Tricuspid insufficiency.— -This is usually secondary to disease of the 
left side of the heart, occurring in its late stages. It. mosl frequently fol- 
lows mitral insufficiency, where it is usually due to dilatation of the right 
ventricle without changes in the valves. It may be secondary to certain 
diseases of the lungs, such as emphysema, chronic interstitial pneun* 
or chronic pleurisy, and it may be due to congenital malformation. Tri- 
cuspid insufficiency gives a systolic murmur, loudesl over the lower pa 
the sternum, but heard usually over a small area. It is generally b 
with signs of dilatation of the right ventricle. The jugular * 
out prominently, and often show systolic pulsatioi ■ tll( ' 

right side. The symptoms associated with tricuspid regurgitatioi 
to general systemic venous obstruction, already mentioned in oonnei 
with mitral insufficiency. 



586 DISEASES OF THE CIRCULATORY SYSTEM. 

Tricuspid stenosis, pulmonic stenosis, and pulmonic insufficiency 
are practically unknown in childhood, except in congenital cardiac 
disease. 

Prognosis of Valvular Disease. — Complete recovery from valvular dis- 
ease is possible only when the lesions are very slight. Few children die 
from cardiac disease before reaching the age of fourteen years, sudden 
death being extremely rare. A large proportion of the cases do fairly 
well up to about the time of puberty, when they begin to lose ground, 
often failing rapidly. Others do well until a fresh endocarditis is lighted 
up by an intercurrent attack of rheumatism, after which the disease may 
make rapid progress. The proportion of children who have serious cardiac 
lesions before the age of eight years, and reach adult life in good condition 
is comparatively small. 

There are several features of cardiac disease in children, in consequence 
of which, serious lesions tend to progress more rapidly than in adults. 
The muscular walls are less resistant, and hence rapid dilatation occurs 
much more readily than in adult life. The heart must provide not only 
for constant needs, but for the growth of the body. If the patient's gen- 
eral nutrition is poor during the period of most rapid growth, this tells 
quickly and seriously upon the heart, and dilatation makes rapid progress ; 
but if the general nutrition continues good the heart may do more than 
hold its own throughout childhood. The demands made upon the heart 
at puberty are especially severe, by reason of the rapid growth of the body 
and the frequency of ansemia and malnutrition. There is always present 
the danger of rapid advances in the disease from intercurrent attacks of 
rheumatism, from which children are more likely to suffer than are older 
subjects. Extensive pericardial adhesions are not infrequent, and seriously 
handicap the heart, greatly increasing the tendency to dilatation. The 
effect upon the heart of poor food, unhygienic surroundings, and general 
malnutrition is much more marked than in adults. 

These unfavourable conditions are in part offset by others in which 
the child has an advantage over the adult. Disease of the coronary ar- 
teries is very rare, and the valvular lesions which are most frequently met 
with; — mitral insufficiency and aortic obstruction — are those which admit 
of the most complete compensation. 

In making a prognosis in any given case, the amount of hypertrophy 
or dilatation which exists is of much more importance than the location 
or the special character of the murmur. The condition of the arterial 
and venous circulation must also be taken into consideration ; also how 
rapidly the disease is progressing, the condition of the patient's general 
health, and how well circumstances will admit of proper hygienic and 
general management. The presence of valvular disease in childhood in- 
creases the danger from every acute disease, especially pertussis, diph- 
theria, and scarlet fever. 



CHRONIC VALVULAR DISEASE. .-^7 

Diagnosis. — Valvular disease is to be particularly distinguished from 
conditions in which there are heard functional or accidental murmurs. 
According to my own experience the latter are quite common even in 
young children. Mistakes usually arise from attaching too much impor- 
tance to the presence of murmurs, and too little to the changes in the 
walls and cavities of the heart, with which valvular disease is almost in- 
variably associated. It is not always possible to decide whether a mur- 
mur is organic or functional until the patient has been for some time 
under observation and treatment, particularly when anaemia is present. 
The diagnostic points, so far as the murmurs are concerned, are men- 
tioned in connection with anaemic murmurs (page 590). 

Treatment. — A child who is the subject of chronic valvular die 
should be under constant medical supervision. Irreparable harm often 
results from wilful, but more frequently from ignorant, disregard of the 
simplest and most important rules of life for these patients. The fi 
should be plainly stated, the course of the disease and the dangers fully 
explained to parents, and, when old enough, to the child himself. At 
the very least the patient should be carefully examined three or four 
times each year, in order that the physician may note the progress of the 
disease, and be able to modify the child's occupation, exercise, and sur- 
roundings, in order to meet, so far as possible, the changing conditions. 
Few patients need more watchful oversight than children with cardiac 
disease. The greatest care should be exercised, especially in all recent 
cases, not to overtax the heart. 

During the stage of compensation, treatment directed especially to the 
heart is rarely necessary. The main purpose should be to maintain the 
patient's general nutrition at the highest possible point during the period 
of active growth. To this end, diet, sleep, study, and exercise should re- 
ceive the most careful attention. If malnutrition and anaemia are allowed 
to go on unchecked until they have become severe, the cardiac di« 
may make rapid strides, and as much harm be done in a few month- as 
otherwise might not occur in years. The special symptoms of malnutri- 
tion and anaemia should be met as they arise, by the same means as when 
they occur under other conditions. The question <>f exercise ami recrea- 
tion is always a difficult one to settle. Often too little latitude is given, 
and the heart, like the voluntary muscles, loses its tone. Every form of 
exercise requiring a prolongei I severe -train Bhould he forbid. leu, particu- 
larly swimming and competitive games, like ball and tennis, and ol 
requiring much running; but Bkating, rowing, mountain-climbii 
back exercise, gymnastics, and even cycling on the level— all in mod 
tion— may be allowed not only without harm, but with I 
fit; but any of these, \\>^\ immoderately, may be productive of | 
injury. All exercise should be taken with regularity and , the 

amount being carefully measured by the child's condition. If thi 



588 DISEASES OF THE CIRCULATORY SYSTEM. 

is a boy who must earn his own living, the physician should see to it that 
the occupation chosen is not one liable to make special demands upon the 
heart. 

Special watchfulness is required at the time of puberty to prevent over- 
pressure in schools, and the development of anaemia or chlorosis. The 
first symptoms of these conditions should be treated energetically, and if 
the heart seems to be overtaxed the child should be put to bed. Patients 
should be so far as possible removed from conditions liable to induce 
fresh attacks of rheumatism. To this end, if possible, they should spend 
the winter and spring months in a warm, dry climate. 

In the stage of failing compensation, the same general conditions are 
present as in adults, and they are to be managed in pretty much the same 
way. When such symptoms are first seen, prolonged rest in bed should 
be insisted upon as the thing most likely to restore the normal conditions. 
Cardiac dropsy with low arterial tension and weak pulse, calls for digitalis. 
An overloaded venous circulation may be relieved by diuretics, or, better, 
by saline purgatives. Iron and tonics generally are indicated, particularly 
strychnine and cod-liver oil. In cases of sudden heart failure, nitroglycer- 
in, ether, and ammonia are as valuable as in adults ; but better, probably, 
than any of these is the use of strychnine hypodermically. 

MYOCARDITIS. 

Disease of the muscular wall of the heart is rare in children, and of 
comparatively little importance, except in connection with the acute in- 
fectious diseases. Myocarditis may, however, occur at any age, even in 
foetal life. As seen in children, it is almost invariably a secondary lesion, 
usually the result of some infectious process. The two diseases which 
furnish most of the cases are scarlet fever and diphtheria. The most 
important local cause is pericarditis with adhesions. 

Lesions. — In extra-uterine life, myocarditis, as a rule, affects the wall 
of the left ventricle, the papillary muscles, or the septum. The heart is 
pale or of a yellowish- white colour, very soft and flabby, and there is fre- 
quently dilatation of the cavities. Small ecchymoses may be seen beneath 
the pericardium. 

Two varieties of myocarditis are described : In the parenchymatous 
form there is a degeneration of the muscle fibre which, according to 
Romberg, is most frequently albuminous, next fatty, and least frequently 
hyaline. There is a loss of the transverse striations, and there may be 
complete disintegration of the fibres. This process may be circumscribed, 
but it is usually diffuse. In the interstitial form the lesion usually occurs 
in small, circumscribed areas. There is an infiltration of round cells be- 
tween the muscular fibres of the heart. The process, when acute, may re- 
sult in absorption or in the production of small abscesses. There may also 
be congestion and minute blood extravasations. In chronic cases it may 



ANEMIC MURMURS. 



5S9 



lead to the formation of larger or smaller areas of dense connective tissue 
resembling cicatrices, in the heart wall. Either the interstitial or the pa- 
renchymatous form may occur alone, but in most of the acute cases they 
are combined. In addition, there is usually some degree of mural endo- 
carditis and inflammation of the pericardium next to the heart wall. 
Dilatation frequently follows ; rarely abscesses may form, which may open 
into the heart or into the pericardium. Cardiac aneurism, and even rup- 
ture, have been known to occur in a child of six years (Hadden's case). 

Symptoms. — These are very rarely sufficiently marked to enable one 
to make a positive diagnosis. In many cases in which advanced lesions 
have been found at autopsy there have been no symptoms during life, 
and in others none until the occurrence of sudden death. This is usu- 
ally from cardiac paralysis, rarely from rupture. In eight cases studied 
by Romberg, which occurred in the course of diphtheria, not one had 
cardiac symptoms during life and two died suddenly. When symptoms 
are present, they are generally those of feeble heart action — a faint apex 
impulse, a slow, weak pulse of irregular rhythm, pallor, dyspncBa, and 
attacks of syncope. In the late stages there may be the physical signs of 
dilatation, with dropsy of the feet or the serous cavities, and scanty urine, 
sometimes containing albumin. 

Diagnosis. — A positive diagnosis of myocarditis is impossible. It may 
be suspected in the course of diphtheria, scarlet or typhoid fever, when 
cardiac symptoms like those mentioned occur, and when pericarditis and 
endocarditis can be excluded by the physical examination. 

Treatment. — This is mainly symptomatic. After severe attac 
those infectious diseases in which myocarditis is liable to occur, and at 
any time when it is suspected, patients should be kept recumbent for 
several weeks, and special care exercised to prevent any sudden exertion, 
as death has occurred from so slight a thing as suddenly sitting up in 
bed. Iron, alcohol, and tonics should be given, the besi of all of these 
being strychnine. Digitalis should be used with caution, and never in 
large doses. In some cases with symptoms indicating imminent heart 
failure, more striking benefit follows the use of morphine hypodermicallj 
than any other plan of treatment. 

ANAEMIC MURMURS. 

As already stated, these are not uncommon even in infancy. They 
may be confounded with organic murmurs, either from congenital mal- 
formations or acquired disease. I have several times found the b 
normal at autopsy in cases where a diagnosis of con enital disease had 
been unhesitatingly made during life, the murmur having been of ana 
origin. In any an»mic infant, as well as older child, one Bbould 
to make a diagnosis either of congenital or acquis I 
the mere presence of a murmur. 



590 DISEASES OF THE CIRCULATORY SYSTEM. 

An anaemic murmur is usually systolic, heard at the base of the heart, 
also in the carotids, often in the subclavian arteries, and occasionally over 
any of the large trunks of the body. The murmur varies from day to day, 
and sometimes it is altered by changing the position of the patient. It 
may be loud enough to be heard over a great part of the chest in front, 
and even behind. There is frequently present a venous hum in the neck. 
There are no signs of hypertrophy, nor is there the accentuated second 
sound so characteristic of mitral disease. The pulse is not usually strong. 
Anaemic murmurs diminish in intensity and ultimately disappear with 
improvement in the general condition of the patient. In some cases one 
must wait for the effects of treatment before giving a positive opinion. 



FUNCTIONAL DISORDERS OF THE HEART. 

Disturbances in the heart's action unconnected with organic disease, 
are rare in infants and young children ; but after the seventh year they 
are not uncommon, becoming in fact quite frequent as puberty approaches. 
One of the most important causes is indigestion ; another is overpressure 
in schools, or anything else leading to nervous exhaustion. In these cir- 
cumstances it is usually associated with other mental or psychical dis- 
turbances. An important predisposing cause is the demand made upon 
the heart by the rapid growth of the body about the time of puberty, 
particularly when this is associated with anaemia. In some of the cases 
there is a definite exciting cause, such as fright or great excitement, and 
it may be due to the excessive use of tea, coffee, or tobacco, especially in 
the form of cigarette-smoking. In a few instances it has been traced to 
masturbation. It may follow any acute disease, such as typhoid fever, 
malaria, or one of the exanthemata, and occasionally it occurs in the 
course of these diseases, or with bronchitis or pneumonia. 

Symptoms. — The usual manifestations are attacks of palpitation ; less 
frequently there is tachycardia (rapid heart) or bradycardia (slow heart). 
The majority of children complain more with functional disturbances 
than with organic disease, certainly while the latter is accompanied by 
compensation. Attacks of palpitation occur in paroxysms. In the severe 
form there is usually a sense of oppression in the region of the heart, 
with some dyspnoea, or even orthopnoea. The pulse is rapid, from 120 to 
130, and is irregular both as to force and rhythm. The carotids pulsate 
strongly. The apex impulse is felt over an increased area, the heart 
sounds are usually strong but irregular, and sometimes a slight murmur 
is heard. The face is pale or flushed. There may be headache, vertigo, 
spots before the eyes, and noises in the ears. Sometimes there is slight 
cyanosis with cold hands and feet, and general perspiration. The fre- 
quency of these attacks depends upon the nature of the exciting cause. 
Their duration is from a few minutes to several hours. 



DISEASES OF THE BLOOD-VESSELS. 591 

Diagnosis. — Functional disorders are differentiated from organic car- 
diac disease only by careful and repeated examinations of the heart. In 
the diagnosis of functional disturbance especial importance is to be at- 
tached to a neurotic or neurasthenic condition of the patient, to the 
presence of some adequate exciting cause, the absence of evidence of 
enlargement of the heart, and the fact that the pulmonic second sound is 
not increased. 

Prognosis. — This in most cases is favourable, for with improvement 
in the patient's general condition, with the growth of the body, and in 
girls with the establishment of menstruation, the attacks usually disappear. 

Treatment. — During the attacks, digitalis in moderate doses should be 
given, also bromides or valerian. The curative treatment is to be directed 
toward the cause. Where no special cause can be discovered a general 
tonic plan of treatment should be adopted, with careful regulation of 
the patient's diet, exercise, and mode of life. All stimulating food, tea, 
coffee, and tobacco should be prohibited. Anaemia should receive its ap- 
propriate remedies. The hours of sleep and study, and the amount and 
character of exercise allowed, should be carefully regulated. Duriug the 
intervals no treatment of the heart is necessary. 

DISEASES OF THE BLOOD-VESSELS. 

Abnormally Small Arteries (Arterial hypoplasia). — This condition is 
not a very common one, but it has attracted a good deal of attention, 
having been studied especially by Virchow. The only thing which is ab- 
normal in the circulatory system may be that the aorta, and Bometimea all 
the large vessels are only two thirds or three fourths their usual calibre, 
or even less. This may interfere seriously with the growth and develop- 
ment of the body, especially of the genital organs, although this result is 
not a constant one. The condition is found occasionally in cases of chlo- 
rosis, and in the congenital cases it may be the chief cause. There is 
usually associated a certain amount of hypertrophy of the heart. The 
other symptoms are anamiia, and sometimes an imperfecl development wi- 
the body. A positive diagnosis during life is impossible. 

Aneurism and Atheroma.— In early life chronic disease of the blood- 
vessels is exceedingly rare, yet a sufficient number of observations have 
been recorded to show thai even young children are not exempt from this 
form of disease. Then- had been reported up to L890 twei I 
of aneurism in patients under twenty years of age (Jacobi).* 
however, only twelve were under fourteen years. Banned 
youngest case, which occurred in a foetus born at about the eighth month, 



* A. Jacobi, Archives of Pediatrics, vol. vii. p. 161. 

f Sarnie, Revue Mensuelle dea Maladies dee fEnfai p. 56. In tta< 

cles will bo found references to mos1 of the reported ca 



592 DISEASES OP THE CIRCULATORY SYSTEM. 

in whose body there was found a large aneurism of the abdominal aorta 
just below the origin of the renal arteries. Of the eleven remaining cases 
occurring in children under fourteen years, in over one half the number 
the arch of the aorta was the part affected. In one case the seat was the 
femoral artery, in another the external iliac, and in still another the 
abdominal aorta. 

Probably the most important etiological factor, as in adult life, is 
syphilis, but in only a few of the cases reported was the evidence of syphi- 
lis conclusive. In two cases there was general tuberculosis. In addition 
to these general causes, aneurism may be due to some local condition, 
such as an erosion from bone, an abscess in the neighbourhood, or to em- 
bolism. The symptoms and course of aneurism in young children do not 
differ essentially from the disease as seen in adults. 

In addition to the cases of aneurism referred to above, I have found 
reports of seven cases of atheroma in very young subjects. In Sanne's 
case the patient was but two years old, and patches of atheromatous de- 
generation were found in several places in the aorta. In Hawkins's case, 
eleven years old, there was found extensive atheromatous disease of the 
aorta, subclavian and carotid arteries. In Filatoff's case, atheromatous 
degeneration affected the arteries at the base of the brain, causing death 
from cerebral haemorrhage. It is interesting to note that in this patient, 
who was only eleven years old, there was also present chronic diffuse 
nephritis with contracted kidneys. A similar condition of the kidneys 
and arteries was observed by Dickinson in a girl of six years. 

Embolism and Thrombosis. — Embolism has already been referred to in 
connection with acute endocarditis. It may be seen at any age, even in 
infancy, but generally occurs in patients over five years old. The emboli 
are usually swept into the circulation from vegetations upon the valves 
of the heart. The symptoms which they produce will depend upon the 
nature of the emboli and the vessels occluded by them. If they lodge in 
the brain they may cause paralysis or convulsions ; if in the spleen, pain 
and swelling of this organ ; if in the kidneys, pain, tenderness, and some- 
times haematuria ; if in the lungs, cough, sometimes accompanied by 
haemoptysis and occasionally by a sharp thoracic pain. If the emboli are 
infectious, they may give rise to abscesses. The pathological results fol- 
lowing embolism are similar to those which are seen in adults. 

The most frequent form of thrombosis, that occurring in the sinuses of 
the brain, is discussed in connection with Diseases of the Nervous System. 
Cardiac thrombi, especially of the right side of the heart, are not infre- 
quently found in patients dying from heart disease, pneumonia, and occa- 
sionally also in other acute inflammatory processes and acute infectious dis- 
eases, particularly diphtheria. These thrombi are in most cases produced 
during the last few hours of life, or just at the time of death, and are of 
no clinical importance. They frequently extend from the heart into the 



DISEASES OF THE BLOOD-VESSELS. 593 

large blood-vessels, particularly the pulmonary artery. Thrombosis occa- 
sionally occurs in all the large vascular trunks in childhood as well as in 
adult life. 

Thrombosis of the internal jugular vein. — Pasteur* reports a case in a 
child two and a half years old, in which the middle of the vein was filled 
with an organized thrombus, and the lower portion obliterated and re- 
duced to a fibrous cord. The symptoms were swelling, oedema, and cya- 
nosis of the face, and dilatation of the facial vein, but not of the external 
jugular. There were clubbing of the fingers and oedema of the feet, but 
not of the arm. The heart was found to be dilated and hypertrophied, 
but was not the seat of valvular disease. The symptoms had existed since 
an attack of pneumonia, eighteen months before death. 

Thrombosis of the vena cava. — Quite a number of cases are on record 
where this has occurred as the result of pressure from large abdominal 
tumours; it has followed new growths of the kidney and large masa - 
tubercular lymph nodes. Xeurutter and Salmon have recorded a case of 
thrombosis, apparently of marantic origin, in a child seven years old. 
The thrombus filled the vena cava, and extended to the origin of the 
hepatic veins and into both femorals. Death occurred from tuberculosis. 
In Scudder's case (seventeen years old) there was apparently obliteration 
(probably congenital) of the inferior vena cava; there was an extensive 
varicose condition of all the abdominal veins. The symptoms of throm- 
bosis of the vena cava are swelling and oedema of the feet— sonietim. 
the abdominal walls and the groin— and very great dilatation of the super- 
ficial abdominal veins. 

Thrombosis of the aorta.— A case has been reported by Leopold in a 
newly-born child which was delivered by version. The thrombus wa 
recent origin, and filled the lower aorta, extending into the femoral artery. 
A case of thrombosis of the aorta occurring in a girl of thirteen years has 
been reported by Wallis. The aorta was very narrow, and probably the 
seat of syphilitic'disease. The thrombus extended from the origin of the 
renal arteries to the coeliac axis. 

Thrombosis in infectious diseases. — There is occasionally seen in 
typhoid fever, but more frequently in diphtheria, thrombosis of 
the large venous trunks, usually of one of the lower extremitii 
symptoms are pain, localized swelling, and partial paralysis. If the ai 
is affected, there may be gangrene. 



* Lancet, February 11, lbbb. 



45 



SECTION VI. 
DISEASES OF THE URO-GENITAL SYSTEM. 

CHAPTER I. 
THE URINE IN INFANCY AND CHILDHOOD. 

While a study of the urine is of much less importance in early life 
than of the symptoms referable either to the digestive or respiratory sys- 
tem, it is deserving of much more attention than it has generally received. 
In infancy especially it is attended with difficulty, owing to the fact that 
it is by no means an easy matter to secure a specimen for examination. 

Methods of Collecting Urine. — In male infants this may be done by 
placing the penis in the neck of a small bottle which lies between the 
thighs and is secured in position by pieces of tape passing over the hips 
and beneath the perinaeum. A still better plan is to use a condom in the 
place of a bottle. The urine of female infants can sometimes be collected 
in a similar way by placing a small cup over the vulva and holding it in 
place by the napkin. In either sex, if the infant is placed upon a chamber 
regularly every ten or twenty minutes for a few hours, it is rarely difficult 
to secure the urine, especially if at the same time a cold hand or a cold 
compress be placed over the bladder; sometimes hot applications will 
answer the purpose better. A small amount, sufficient to test for albu- 
min, may often be obtained by placing absorbent cotton over the vulva or 
penis. The most certain of all means, however, is catheterization; in 
females sometimes nothing else will answer the purpose. A soft rubber 
catheter, size 6 or 7, American scale (9 or 11 French), should be used for 
infants. 

Daily Quantity. — This is relatively much larger in infants than in 
older children and in adults, on account of the more active metabolism of 
the young child and the large amount of water taken with the food. The 
quantity fluctuates widely from day to day according to the amount of 
fluid food taken and the activity of the skin and bowels. The following 
figures are the averages obtained by combining the results of the investi- 
gations of Schabanowa, Cruse, Camerer, Pollak, Martin-Ruge, Berti, 
Schiff, and Herter : 

594 



THE URINE IN INFANCY AND CHILDHOOD. 






Average Daily Quantity of Urine in Health. 



Age. 



First twenty-four hours . . , 
Second twenty-four hours.. 

Three to six days '. 

Seven days to two months . 

Two to six months 

Six months to two years. . . 

Two to five years 

Five to eight years 



Eight to fourteen years 1,000 



Grammes. 


Ounces. 


Oto 


60 


to 2 


10 " 


90 


i " 3 


90 " 


250 


3 M 8 


150 " 


400 


5 M 13 


210 " 


500 


: M 16 


250 " 


600 


8 - -Jo 


500 " 


800 


Hi " 26 


600 " 


1,200 


20 " 40 


1,000 " 


1,500 


32 " 48 



Frequency of Micturition.— This is greatest in young infants, and 
diminishes steadily as age advances. In the first two years, during the 
waking hours, the urine is generally passed as often as twice an hour, while 
during sleep it is retained from two to six hours. By the third year the 
urine may be held during sleep for eight or nine hours, and at other times 
for two or three hours. Such control of the sphincter of the bladder is 
often obtained at two years, and sometimes even at an earlier period. 
From slight nervous disturbances or minor ailments of any kind, this con- 
trol is impaired, and the water may be passed by children of four or live 
years with, the frequency seen in infants. 

Physical Characters. — The urine of the newly-born is usually highly 
coloured. During later infancy it is pale and frequently turbid, even 
when practically normal, owing to the presence of mucus; this turbidity 
of ten no amount of filtration will entirely remove. Less frequently tur- 
bidity depends upon urates. The urine of the first few days of life often 
shows a deposit of urates or uric acid in the form of a reddish-yellow 
stain upon the napkin. The reaction of the urine at this time is usu- 
ally strongly acid, but throughout the rest of infancy it is faintly acid <>r 
neutral. 

The specific gravity is higher during the first two days than at any 

time in infancy on account of the scanty supply of fluid taken ; it is 

usually lowest from the third to the sixth day, hut from this time it 

steadily until puberty is reached. The specific gravity will <»!* course wury 

with the quantity. From the writers already referred t<» the following 

figures are taken : 
° Specific graTity 

First to third day L'OlOto I 

Fourth to tenth day 1-004 " I I 

Tenth day to sixth month 1*004 M ' 

Six months to two years 1*006 - I 

Two to eight years 1 008 " > 

Eight to fourteen years 1 '012 " 1 

Microscopically, the urine of the newly-born shows the pr< 

many squamous epithelial cells, muCUS, granular matter, and or 



596 DISEASES OP THE URO-GENITAL SYSTEM. 

uric acid and amorphous or crystalline urates. It is not uncommon to 
find hyaline and even granular casts. Martin-Ruge found hyaline casts 
in the urine of fourteen out of twenty-four healthy nursing infants ex- 
amined during the first week. Granular casts were much less frequent. 
The microscopical appearances of the normal urine of later infancy and 
childhood present no peculiarities. 

Composition. — Urea. — The following figures show the average daily 
quantity of urea eliminated at the different ages : 

Age. Daily quantity of urea. 

First day 0-076 to 0*114 gramme. 

Second to seventh day 0-140 " 0*660 

One to two months 0'90 " 1*40 

Three to five years 13-09 " 14*01 grammes. 

Five to thirteen years 16-05 "21*03 

Uric acid. — Few observations have been made upon the elimination 
of uric acid, but all authorities agree that it is much higher in the newly- 
born than at any subsequent period of life. The quantity is better ap- 
preciated by giving the ratio between the uric acid and urea than by the 
absolute quantity of the former. The figures here given for the newly- 
born are taken from Martin-Ruge ; the others are from Herter. 

Ratio of Uric Acid to Urea. 

In the newly born 1 to 14 

Under one year 1 " 60-80 

From two to five years 1 " 50-70 

From five to fifteen years 1 " 45-60 

The inorganic salts (phosphates, chlorides, sulphates) are all present 
in the urine of the newly-born, but in relatively small quantity, increasing 
as age advances. The colouring matters are also less abundant. 

Albumin is often present in the urine during the first days, but usu- 
ally in small amount. Cruse found it twenty-eight times in ninety obser- 
vations upon healthy infants ; usually the quantity was small, amounting 
to traces only, but in two cases it was quite large upon the second day. 
These observations are confirmed by the investigations of Martin-Ruge, 
and also of Pollak. 

Sugar is frequently found in the urine of healthy infants during the 
first two months. This subject is referred to later under the head of 
Glycosuria. 

FUNCTIONAL OR CYCLIC ALBUMINURIA. 

Etiology. — This condition, although a rare one in young children, is 
quite common between the ages of ten and sixteen years. I shall not in 
this connection include cases sometimes classed as febrile albuminuria, in 
which there is usually present the condition described as acute degenera- 
tion of the kidneys. 



FUNCTIONAL OR CYCLIC ALBUMINURIA. 597 

The causes of functional or physiological albuminuria, and the cir- 
cumstances in which it has been observed, are many and varied. It is 
much more common in males than in females. In many patients it is 
regularly cyclic in character, albumin being absent in the urine passed 
during the night or early morning, but present during the day, diminish- 
ing in the evening and absent at bed-time. In a case reported by Tiemann, 
the morning urine showed no trace of albumin in seventy-eight of eighty- 
four examinations. At noon albumin was present in ninety-eight of 
one hundred and thirteen examinations. In certain cases albuminuria is 
distinctly traceable to cold bathing; in others, to fatigue following ex- 
cessive muscular exercise ; in still others, to dyspeptic conditions. It may 
be associated with a diet rich in nitrogenous food. In other cases none 
of these conditions exist, and there is simply the occasional presence of 
albumin in the urine. 

Many theories have been advanced in explanation of cyclic albuminuria. 
Sometimes it appears to be clearly traceable to irritation of the kidney by 
uric acid, urates, and oxalates. Kinnicutt believes this to be one of the 
prominent causes, and that albuminuria is due to vaso-motor disturbances 
in the kidney. Delafield compares the exudation of serum from the ves- 
sels of the kidney to the dropsy of the feet seen in anaemia. Da I 
believes that it always depends upon slight changes of an evanescent char- 
acter in the kidney. 

Symptoms. — Many of the patients exhibiting cyclic or periodical al- 
buminuria are well nourished, and have no other signs of disease; others 
show dyspeptic symptoms, and are anaemic and poorly nourished, suffering 
from headaches and other neuroses. In the cases distinctly periodical the 
amount of albumin is commonly small. It is not infrequently associated 
with temporary glycosuria. As a rule, casts are absent, although it is no1 
uncommon to find a few hyaline casts, and occasionally granular casts are 
also present. A gouty family history exists in a certain proportion of the 
cases, and some of the patients themselves present other evidences of this 
diathesis. 

Diagnosis.— Pavy mentions the following points as characteristic of 
physiological or functional albuminuria: (1) The time of in occurrence. 
The absence of albumin early in the morning, its presence in the i 
noon, and diminution toward evening. When this is repeated day 
day the diagnosis is, he believes, quite positive. (2) The ab 
ous impairment of the general health and of the characteristic Bynipt 
of nephritis, such as dropsy, cardiac hypertrophy, a pulse of higl 
retinal changes, etc. (3) The fact that casts are, as a pule, absent. (4) 
That crystals of oxalate of Lime are present, aid the urine is of high 
specific gravity. 

Too much stress is certainly laid by Paw and many other enters 
upon the fact that the albumin is found in the urine only at ecrtam 



598 DISEASES OF THE URO-GENITAL SYSTEM. 

times in the day. This is not characteristic of functional albuminuria, as 
the same thing occurs in many cases of chronic nephritis, especially in 
the early stages when the amount of albumin present is small. All these 
cases must be carefully watched for a long time and many observations 
made, before nephritis can positively be excluded. 

Prognosis. — The prognosis in cases of purely functional albuminuria is 
good. It is to be remembered that patients who for a considerable time 
have been regarded as having only functional albuminuria have ultimately 
developed nephritis ; hence an absolutely favourable prognosis is possible 
only after a long period of observation. If albumin is constantly present 
it is probably pathological, and the longer it continues the more serious is 
the outlook. 

Treatment. — This is to be directed toward the patient's general condi- 
tion rather than to the kidneys and the urine. The dyspeptic symptoms 
must be relieved, the patient's mode of life regulated, only moderate exer- 
cise allowed, and a simple diet given which does not consist too largely of 
nitrogenous food. If the urine is of high specific gravity, and contains 
oxalate-of-lime crystals, alkalies and mineral waters should be given in 
addition. Iron is indicated if there is anaemia present. 

HEMATURIA. 

Haematuria is characterized by the presence of red blood-cells in the 
urine, and is to be distinguished from haemoglobinuria where only blood 
pigment is present. 

Haematuria may result from local or general causes. In infancy it 
may be due to new growths of the kidney. In such cases the haemor- 
rhages are often abundant, and may be the first symptom of the condition. 
Haematuria may occur also as a symptom of acute nephritis, especially 
that complicating scarlet fever, or it may result from the irritation of a 
calculus in the kidney, the ureter, or the bladder. In rare instances its 
cause is a new growth of the bladder, and it may be due to traumatism. 
Among the general causes the most important are : the haemorrhagic dis- 
ease of the newly-born ; the blood dyscrasiae, such as scurvy, purpura, and 
haemophilia ; and infectious diseases, particularly malaria, typhoid, variola, 
scarlet fever, and influenza. In most of these cases the amount of blood 
passed is small. When it is large it may appear in the urine as clear 
blood, or as clots, or it may impart simply a reddish or smoky colour to 
the urine. The colour, however, is not a reliable guide ; the best of all is 
the microscopical examination. For a simple chemical test guaiacum may 
be used. 

To discover the source of the blood may be quite difficult. Large 
haemorrhages are much more likely to come from the kidneys than from 
the bladder. The presence of blood casts from the renal tubules, or larger 



GLYCOSURIA. 599 

ones from the ureter, are conclusive evidence of the renal origin of the 
haemorrhage. 

In children, renal haemorrhage in itself rarely requires treatment ; 
when it does, the same remedies are indicated as in the adult, viz., ergot, 
gallic acid, and rest in bed. Some obstinate cases have been cured by 
drinking water from alum springs. 

HEMOGLOBINURIA. 

In this condition blood pigment appears in the urine in large quantity, 
but red blood-cells are very few in number, or are absent altogether. In 
severe cases the urine may be almost black. There is commonly a small 
amount of albumin. This condition may be recognised by the appearance 
of granules of pigment under the microscope, or by Heller's test; the 
most conclusive means of diagnosis, however, is the spectroscope. 

Epidemic haemoglobinuria (Winckel's disease) has already been de- 
scribed in the chapter on Diseases of the Newly-Born. Haemoglobinuria 
may be due to certain poisons, as carbolic acid or chlorate of potash, or to 
certain infectious diseases, as scarlet fever, typhoid fever, malaria, syphilis, 
and erysipelas. 

Paroxysmal haemoglobinuria occurs in childhood, although it is an 
exceedingly rare condition. A typical case in a child of four and a half 
years has been reported by Mackenzie. This was a delicate child of syphi- 
litic parents ; here the haemoglobinuria was preceded by fever and chills, 
without any other evidence of the presence of malaria. 

The exact pathology of haemoglobinuria is at present unknown, and 
its treatment is very unsatisfactory. 

GLYCOSURIA. 

By this term is understood the occasional or transient appearai 
sugar in the urine. This is not very infrequent in children, and may be 
met with even during the first month of life. Gr6sz has published s 
careful investigations upon the glycosuria of early Infancy.* lb- made 
many observations upon fifty infants during the first month <»f life, from 
which the following conclusions were drawn : Glycosuria is no1 uncommon 
in nursing infants; but it is not seen in nursing infants win. are per- 
fectly healthy. It occurs particularly with certain disturbances of d 
tion, whether functional or inflammatory. The sugar found in the u 
under these conditions reacts strongly to the reduction 
but not to the fermentation test; sometimes tin- polariscope il 1' 

has the power of dextrorotation. This is believed tobemilk sugar, or 
of its derivatives. It is not of constant or regular occurrence, It may be 



* Jahrbuch fiir Kinderheilkunde, Bd, ixxir, p. 



600 DISEASES OP THE URO-GENITAL SYSTEM. 

produced artificially by increasing the amount of milk sugar above that 
which can be normally absorbed. This quantity Grosz places at 3*3 
grammes for each kilogramme of the body weight. If more than this is 
given, or if there is diminished capacity for the absorption of sugar, gly- 
cosuria occurs. 

Koplik has made some observations upon the urine of patients 
fed chiefly upon infant foods composed largely of sugar. He found 
suo*ar in five out of ten cases examined ; in three, the sugar responded 
both to Fehli rig's and the fermentation test ; in two cases to Fehling's 
test only. 

There seems to be no doubt regarding the existence of dietetic glyco- 
suria in infants and in older children. Eepeated examinations of the 
urine are, however, necessary in order to exclude more serious disease. 

PYURIA. 

Pus in the urine may exist as an acute or a chronic condition. In 
either case, in a child, it is much more likely to come from the pelvis of the 
kidney than from any other source. It may, however, come from any part 
of the genito-urinary tract — the kidney or its pelvis, the ureters, the blad- 
der, the urethra, or the vagina. Sometimes it comes from an outside 
source, as when an abscess from perinephritis, appendicitis, or caries of 
the spine opens into the urinary tract. 

Coming from the pelvis of the kidney, pus may indicate, if the 
condition is an acute one, pyelitis, pyelo-nephritis, or pyonephrosis ; if it 
is chronic, it points to renal tuberculosis or calculus. The amount of pus 
in any of these conditions may be quite large. The urine is turbid and 
usually acid in reaction. It contains many epithelial cells of the transi- 
tional forms described in the article on Pyelitis. The urine when con- 
taining much pus is always albuminous. A turbidity due to pus may be 
mistaken for an excessive deposit of urates, but a microscopical examina- 
tion quickly reveals its true nature. It is rare that pus comes from the 
ureters except in connection with congenital malformations or the im- 
paction of calculi. Pus from the bladder is usually in small quantity, 
especially in young children, and it is mixed with mucus. The urine may 
be alkaline or acid in reaction ; there are associated the symptoms of vesi- 
cal irritation or of cystitis. Pus from the lower genital tract is rare in 
children, but its causes are usually easily recognised by a local examina- 
tion. When the cause of pyuria is the opening of an abscess into the 
urinary tract there is generally a sudden appearance of pus in large 
amount. It is in most cases of short duration, possibly only a few days, 
and it may disappear quite rapidly. 

The treatment of pyuria depends altogether upon its cause. Improve- 
ment in the symptoms sometimes follows the use of benzoic acid or ben- 



LITHURIA. 601 

zoate of ammonia in doses of from two to five grains every three hours to 
a child of five years. It is especially indicated where the urine is Btrongly 
alkaline. 

LITHURIA. 

Lithuria is a condition in which there is an excessive elimination in 
the urine of uric acid or of urates. The amount of nitrogen compounds 
eliminated by the kidneys as uric acid and urea, varies much from day to 
day with the nature of the food and other conditions. Hence in estima- 
ting an excess of uric acid, the absolute quantity eliminated in twenty- 
four hours is much less significant than the ratio of the uric acid to the 
urea (page 596). Whenever this ratio is continuously disturbed, the excre- 
tion of uric acid may be considered abnormal, except, of course, in grave 
pathological conditions of the kidney, where there is an insufficient elimi- 
nation of urea. Eegarding the source of uric acid, the theory of Horbac- 
zewski is that most widely accepted, viz., that it results from the destruc- 
tion of the nuclein of the cells of the body, particularly of the white 
blood-cells. 

For accurate knowledge as to the amount of uric acid eliminated, 
nothing short of a quantitative chemical analysis can be depended up< n. 
But if amorphous urates are deposited in large amount, uric acid ma; 
considered excessive if the specific gravity is not high (above 1.025). If 
the specific gravity is high, the precipitation may be explained simply by 
the concentration of the urine. The deposition of the crystals of uric 
acid, forming the familiar brick-dust deposit, is not evidence of excee 
elimination. For a quantitative clinical test, that of Haycroft is probably 
the be#t>* 

Lithuria is not a specific condition, but rather a very general Bymptom 
associated with many kinds of disturbances of nutrition. It may be found 
in angemia, malnutrition, chorea, rheumatism, chronic dyspepsia, and in a 
great variety of other disorders. Regarding the significance of lithuria, 
thus much maybe positively asserted : The excessive elimination of uric 
acid when continuous is always evidence of a serious disturbance of nutri- 
tion. The gravity of the condition will depend upon the degree of this 
excess and upon its duration. 

The treatment of lithuria is the treatment of the condition upon which 
it depends. The essential pathological condition is no! so much i 
elimination as excessive production. 

Urine containing Crystals of Uric Acid in the Form of Brick 
Deposit.— This condition is not to be confounded with the one just 
described. As already stated, such precipitation ia no1 to be taki 
dence of an excess of uric acid, and, in fact, in most there 



•SeeHaigon [JricAcidiE Beolthand D 



602 DISEASES OP THE URO-GENITAL SYSTEM. 

is no excess. The condition is rather one in which the solvent power of 
the urine for uric acid is much reduced. Such urine, as a rule, is high- 
coloured, strongly acid, and may have a high specific gravity. 

This condition also is dependent upon a disturbance of nutrition, and 
one which is most frequently associated with a gouty diathesis. It is not 
very common in children except in those of gouty antecedents. In such 
patients it is only occasionally present, and is usually associated with some 
other disturbance of nutrition, often of digestion. It is frequently the 
cause of local irritation of the urinary passages, which is usually slight, but 
which may be severe. 

In my experience these cases are most improved by cutting off sugar 
from the diet almost entirely, by greatly reducing the amount of starchy 
food and substituting a diet rich in nitrogen and fat, viz., meat, milk, 
and cream, together with plenty of outdoor exercise. The continued use 
of alkaline waters is also of decided advantage in most cases. 

INDICANURIA. 

Indicanuria is a condition characterized by the presence of indican in 
the urine. To Herter is due the credit of bringing this subject promi- 
nently to the minds of the profession in this country. Indican (indoxyl- 
potassium sulphate) is derived from indol, which is formed in the intes- 
tine by the agency of bacteria from the excessive putrefaction of the 
proteids. It may also be produced in other parts of the body where putre- 
factive processes are going on, as in extensive suppuration without drain- 
age, in pulmonary cavities, empyema, etc. Indican is only one of the 
ethereal sulphates produced in the manner above indicated, and when 
other conditions like those mentioned are excluded it may be taken as an 
index of the amount of putrefaction going on in the intestine. 

The presence of indican in the urine is demonstrated by adding certain 
oxidizing agents, which produce an indigo-blue colour.* The existence 



* The commonly employed test for indican is that known as Jaffe's test. It is 
described by Herter as follows : Pour into a test-tube equal quantities of urine and 
strong hydrochloric acid so as to fill the tube to within half an inch of the top, and 
shake. If there is much indican, a dark blue or purple colour will be produced. Then 
add sufficient chloroform to completely fill the tube and shake thoroughly. It is 
important that the chloroform should completely fill the tube so that no air bubbles 
get in by the agitation. If, after standing, the chloroform assumes a deep-blue or vio- 
let colour, there is certainly an excess of indican. The reaction may not appear at 
first, but may come out after standing several hours, or if slight at first it may in- 
crease in intensity. Sometimes, when no reaction is obtained, it may be produced by 
adding one drop of a saturated solution of chloride of lime or of peroxide of hydro- 
gen. No more than one drop should be added at a time, or the blue colour may be 
bleached. In alkaline urine the indican is usually destroyed, so that the test may be 
negative. 



ACETONURIA— DIACETOXURIA. 603 

of indicanuria in children was formerly believed to be pathognomonic of 
tuberculosis. Later investigations have shown that this is not the case ; for 
in cases of tuberculosis indican is almost as frequently absent as present. 

Herter gives the following as the conditions under which indicanuria 
is likely to be present : It is found in chronic intestinal indigestion ; in 
very many cases of chronic constipation ; in many cases of epilepsy, just 
about the time of the seizures; in some cases of masturbation ; frequently 
in children who are the subjects of night terrors, and in whom there 
are usually disturbances of digestion. According to other obsen 
it is found with great constancy in acute putrefactive diarrhoeas. With 
the exceptions above noted, the source of the indican is always the 
same, viz., the excessive putrefaction of the proteid substances in the 
intestine. 

Indicanuria is most frequently a symptom either of acute or chronic 
intestinal disease. It is important as being a guide by which we may esti- 
mate the other symptoms in these conditions, and the effects of treatment. 
While a trace of indican is frequently present in health, a strong indican 
reaction is always to be considered abnormal in a child. The indications 
for treatment are to diminish intestinal putrefaction. This is mainly 
dietetic, and is to be accomplished by means referred to in the treatment 
of chronic intestinal indigestion (page 3G8). 

ACETONURIA— DIACETOXURIA. 

Acetone exists in small quantities in the urine of healthy children. 
According to Baginsky and Schrach, it is found in large quantities in 
many febrile diseases. It increases with the height of the fever and 
subsides with it. Acetone is probably formed from the destruction of 
the nitrogenous material of the body, as it is increased by a nitrogenous 
diet, and may disappear by a diet of carbohydrates. Baginsky found it 
also in children with epilepsy, sometimes during the attacks. It is not, 
however, believed to be the cause of the convulsive seizures, as it is •> 
in convulsions occurring under other conditions. It has no relation to 
rickets. According to Schrach, there is no connection between acetonuria 
and the nervous symptoms accompanying fever. Von Jaksch found 
tone in a case of diabetic coma. 

Binet found diacetic acid in sixty-nine ou1 of one hundred and fifty 
examinations in febrile diseases, chiefly in scarlel fever, □ 
monia. In diabetes this condition often precedes the development of 
coma, otherwise it is of no prognostic Bignificanc ■ 8 irach found d 
tonuria exceedingly common in all cases of continuous high fever. [I 
more frequently present than acetonuria, and ceases with the fever.* 



* For literature, see Baginsky, Arehiv fur Kinderheilkunde, Bd. xi. p, 1. 



604 DISEASES OF THE URO-GEN1TAL SYSTEM. 



ANURIA. 

By this term is meant an arrest of the urinary secretion. To that form 
which occurs in the course of renal disease the term " suppression " is gen- 
erally applied. Anuria is to be carefully distinguished from retention, 
from the scanty secretion which occurs whenever food is refused or with- 
held on account of illness, and also from that which accompanies acute 
diarrhoea with large, watery discharges. Anuria is sometimes seen in the 
newly-born, where it depends upon some malformation of the genital 
tract ; or it may depend upon uric-acid infarctions in the kidneys. The 
first urine passed after such an attack is very often highly acid, and 
may contain an abundance of uric-acid crystals and larger masses visible 
to the naked eye. Other cases admit of no such explanation, and the 
condition must be regarded as of nervous origin. For the time, the 
secretion appears to be completely arrested, as the bladder, both by pal- 
pation and catheterization, is found to be empty. This condition is not a 
very uncommon one in infancy, and it may continue for from twelve to 
thirty-six hours. So long as infants appear to be perfectly normal in 
every other respect, the suspension of the urinary secretion even for 
twenty-four hours need excite no anxiety. 

The treatment is very simple and effectual, and consists in the admin- 
istration of sweet spirits of nitre, either alone or in combination with the 
acetate or citrate of potash, and plenty of water. To an infant of three 
months one minim of the nitre and one grain of the citrate of potash may 
be given every hour in half an ounce of water until the urinary secretion 
is established, which will usually be in six or eight hours. If the urine is 
very highly acid, and stains the napkins, the potash should be continued 
for several days. Hot fomentations over the kidneys may be used with 
advantage. 

DIABETES INSIPIDUS (POLYURIA). 

This is a chronic disease characterized by the excretion of a very large 
amount of pale urine of low specific gravity. It is invariably accompanied 
by polydipsia. The disease is an exceedingly rare one in children. 

The exact pathology of diabetes insipidus is not known ; but from the 
conditions under which it occurs it is believed to be a neurosis. The 
irritation which gives rise to it may be in or near the floor of the fourth 
ventricle, or it may affect the renal nerves. 

Etiology. — Of eighty-five cases collected by Strauss, twentj'-one were 
under ten years of age and nine under five years. In Boberts' collection 
of seventy cases, the disease began in twenty-two before ten years, and 
in seven during infancy. In some cases it begins soon after birth. Males 
are more frequently affected than females, and in certain cases heredity is 
an important factor. Weil has published a remarkable example of the 



DIABETES INSIPIDUS. 



605 



disease existing in many members of a single family. Falls or blows upon 
the head, concussion of the brain, tumours of the brain, especially of the 
occipital region, tubercular or cerebro-spinal meningitis or chronic hydro- 
cephalus, all have been found associated with diabetes insipidus. It some- 
times has followed the acute infectious diseases; but in many cases no 
cause whatever can be found. 

Symptoms. — The quantity of urine is enormous, usually exceeding even 
that in diabetes mellitus. From five to twenty pints daily may be passed. 
The urine is pale, the specific gravity from 1-001 to 1*000, and it contains 
neither albumin nor grape sugar. In a few cases the presence of inosite 
(muscle sugar) has been found. Restricting the amount of fluid taken 
causes a very marked diminution in the amount of urine. The intense 
thirst leads patients to drink enormously of water and other fluids. Vari- 
ous contradictory statements are made by different writers regarding the 
quantity of uric acid and urea eliminated in these cases. The following 
are the results obtained in a case recently under observation in the Babies 1 
Hospital.* The child was three years old, quite anaemic, and losing in 
weight. On January 20th the fluids were unrestricted, on the other days 
they were restricted : 



Date. 


Daily quantity of 
urine. 


Specific 
gravity. 


Total 
urea. 


Total 
uric acid. 


[ndican 
reaction. 


. 


January 20 


Grammes. 
3,300 

750 

775 
1,320 


Ounces. 

10H 

25 

25i 
49' 


1-006 
1-010 
1-010 
1-007 


Grammes. 

22-276 
9-049 
6-478 

12-113 


Qrammea 
0-173 

0-072 

6-iio 


None, 
Strong. 

None. 


None. 


" 25 


None. 


»« 26 


None. 


February 8 









The elimination of urea in this case is excessive, but the uric acid is 
not far from the normal. 

Nervous symptoms are usually present. There may be disturbed 
from the frequent micturition, palpitation, flushing of the face and other 
vaso-motor disturbances, headache, restlessness, and neuralgia. There 
maybe incontinence of urine. The skin is pale and dry, and perspiration 
is scanty. The general health may not be disturbed. In mosl cases, how- 
ever, it is somewhat affected, and then' may be the usual symptom 
malnutrition, and even neurasthenia. U it affects young child] 
growth maybe considerably retarded. The appetite usuallyreraa 
good. The temperature is at times slightly subnormal. T 
the disease is indefinite. It is very chronic, and may last for ma] 
death taking place only from intercurrent affections. 

Prognosis.— A few of the eases recover spontaneously. 
duration are often cured by treatment, of the chro] in which 



* The analyses were made by Dr* < '. A. B 



606 DISEASES OF THE URO-GENITAL SYSTEM. 

the disease is well established very few are controlled. The prognosis is 
worse if there are marked disturbances of the digestive tract or organic 
brain disease. 

Diagnosis. — This is easily made from the two marked symptoms, ex- 
cessive thirst and the polyuria. From diabetes mellitus it is easily distin- 
guished by the low specific gravity and the absence of' sugar from the 
urine. In older children, chronic nephritis with contracted kidney may 
be confounded with it. 

Treatment. — Fluids should be moderately restricted. It is a serious 
mistake to reduce the quantity of fluids too much, since the drinking is 
not the cause of the diuresis. The diet should be simple and nutritious, 
consisting largely of meat, with a moderate amount of carbohydrates. The 
general treatment should be directed to the condition of malnutrition. 
The clothing should be warm, and a moderate amount of exercise should 
be allowed. Drugs are of little use ; those which have sometimes been 
beneficial are arsenic, belladonna, ergo tine, the bromides, and antipyrine. 
Treatment must be continued for many months to be of any value. 



CHAPTER II. 

DISEASES OF THE KIDNEYS. 
MALFORMATIONS AND MALPOSITIONS OF THE KIDNEY. 

Malformations of the kidney are not infrequent. In seven hun- 
dred and twenty-six consecutive autopsies at the New York Infant Asy- 
lum malformations of the kidney or ureters were met with in seventeen 
cases. This does not represent the actual frequency with which they 
occur, for in about half the number of autopsies in two other institutions 
only a single example was seen. Adding to the cases mentioned two 
others seen elsewhere, there are twenty cases of renal malformation of 
which I have notes, classed as follows : 

Fusion of the kidneys, or horseshoe kidney 4 cases. 

Supernumerary ureters 4 " 

Hydronephrosis (alone) 8 " 

Cystic degeneration of the kidney (alone) 2 " 

Hydronephrosis and cystic kidney 1 case^ 

Single kidney 1 " 

In all malformations the left kidney is much more frequently affected 
than the right, the proportion being nearly two to one. Malformations 
are more often seen in males than in females. 



MALFORMATIONS AND MALPOSITIONS OF THE KIDNEY. GOT 

Fusion of the Kidneys. — In one case, in a child who died of pneumonia 
at the age of three years, the kidneys were fused into one irregular ovoid 
mass, lying upon the lumbar vertebrae ; in another case the mass lay upon 
the promontory of the sacrum ; in both there were two renal arteries and 
two ureters. In the two other cases the organs were united at their lower ex- 
tremities, and in both of these there were two ureters passing in front of the 
kidney. In one there was also hydronephrosis and chronic diffuse nephritis. 
The children died at the ages of four and five months respectively. 

Cystic Degeneration of the Kidneys. — In two of these three cases the 
right kidney was affected, and in one the left. The ages at which the chil- 
dren died were from seven to ten months. Xo renal symptoms were pres- 
ent. In all the cases the cystic kidney was very small, about an inch and 
a half in length and one inch in width. The organ was entirely made up 
of smaller and larger cysts containing a clear fluid, held together by loose 
connective tissue. The ureter was small and rarely pervious throughout. 
In one case there was hydronephrosis of the opposite side ; in the others 
the opposite kidney was considerably enlarged, being about one half larger 
than normal. In addition to these small cystic kidneys there has been 
described a cystic degeneration in which very large cysts have formed even 
in utero, sometimes filling the abdominal cavity of the child and seriously 
interfering with delivery. 

Single Kidney, the other being rudimentary or absent. — Of this I have 
seen but one example, which was found in a young man twenty- two 3 
of age, who died of typhus fever in Bellevue Hospital. The right kidney 
weighed seven and a half ounces; the left was represented by a nodular 
mass about the size of an ovary, showing no trace of renal tissue. Tin- 
ureter was pervious to within four inches of the kidney; the Buprarenal 
capsule was normal. Macdonald has reported a case in which there \\;i- 
no trace whatever of the right kidney ; the left was greatly enlarged, and 
weighed nine ounces. There were two suprarenal capsules hut only one 
ureter. Schaeifer has reported absence of both kidneys in a Beven-months' 
foetus, associated with many other malformations. 

Hydronephrosis. — Of the ten cases of which I have notes, this «■•• 
as the principal deformity in eight. In two eases it was associated respec- 
tively with cystic degeneration of the opposite kidney and horseshoe kid- 
ney. In seven cases only the left side was affected; in three there 
double hydronephrosis. Seven patients were males and three fenu 
Six died before they were six months old, and only two lived b 
years old. This condition is undoubtedly tin- resall of Borne obstruction 
to the outflow of urine in the meter, bladder, urethra, or prepuce, but in 
only three of my cases could there 1m- found an obstruction sufficient to 
explain the deformity. In two then- was marked hypertrophy <-f the 
bladder. In no case was a calculus found as 1!- -; ruction. 

In most of the cases the ureter was dilated to a diameter -1' from 



608 DISEASES OF THE URO-GENITAL SYSTEM. 

fourth to one half of an inch, and in two it was so large as to be easily 
mistaken for the small intestine. Usually the ureters appeared much elon- 
gated and sacculated ; the pelvis of the kidney was dilated to the capacity 
of half an ounce or more, the calices forming pockets about half an inch in 
diameter. Less frequently the greater part of the kidney was destroyed, 
leaving only a series of communicating pockets surrounded by a thin cortex 
of renal tissue from one fourth to one eighth of an inch in thickness. In 
five cases there was chronic diffuse nephritis of the affected side, and 
sometimes both kidneys were involved, even though the hydronephrosis 
was unilateral. The nephritis was usually of a very advanced type. In 
two cases, typical examples of the atrophic form (contracted kidney) were 
seen, one of these children dying at the age of one month.* The organs 
are shown in Fig. 105. In two of the cases the bladder was the seat of 
very marked hypertrophy. 

Urinary symptoms were noted in but one case, and in that they were 
due to pyelo-nephritis dependent upon the presence of calculi in the kidney 
not the seat of hydronephrosis. In no other case was the malformation sus- 
pected during life. Four patients died of marasmus, two of acute broncho- 
pneumonia, and one of ileo-colitis. In only one was there any malforma- 
tion outside the urinary tract, this being a case of congenital heart disease. 

Double hydronephrosis is generally associated with, or results in, such 
changes in the kidneys that the patients die during infancy, commonly 
in the first year. At this age it rarely gives rise to a tumour, and is rec- 
ognised only by the changes in the urine or by the other symptoms of 
nephritis. There may be the general and local symptoms of chronic dif- 
fuse nephritis, or, when infection of the genital tract occurs, there are 
added the symptoms of pyelitis. In the great majority of cases the con- 
dition is unrecognised, the patient dying of some disease not perhaps in 
itself fatal, but rendered so by the condition of the kidneys. 

If hydronephrosis is unilateral there may be no symptoms until the 

* This was in every way a remarkable case. The child died apparently of maras- 
mus. There was double hydronephrosis, the ureters being three fourths of an inch in 
diameter. The right kidney was nodular upon the surface, and had a very adherent 
capsule. Just beneath the capsule there were small cysts containing pus. The left 
kidney was the seat of hydronephrosis, only its cortex remaining, this being about one 
sixth of an inch in thickness. Microscopical examination showed great thickening of 
the capsule of the right kidney, and several small abscesses encapsulated in the cortex 
just beneath the capsule. The rest of the kidney was converted into a mass of dense 
fibrous tissue in which were scattered many uriniferous tubules, the epithelium of 
which was clear, nucleated, and of the embryonic type. The left kidney was the seat 
of chronic diffuse nephritis of the atrophic variety, with well-marked changes in the 
medullary portions. The cortex showed much exudation and less atrophy, being nearly 
normal in thickness. The small size of the organ was due chiefly to atrophy of the 
pyramids. The walls of the bladder were greatly hypertrophied, being in places one 
fourth of an inch thick. The urethra and prepuce were normal. 



MALFORMATIONS AXD MALPOSITIONS OF THE KIDNEY. 



609 



dilatation of the pelvis of the kidney has reached a sufficient size to form 
an abdominal tumour. In most of the cases in children this condition 
has been noted between the third and the eleventh years. This tumour 
may be situated in the lumbar region, or it may fill the abdomen. It is 
cystic, and may be confounded with a dermoid cyst of the ovary. On 




Fig. 105. — Congenital hydronephrosis, dilated ureters, and bypertrophied bladder. (I i 

en.- month old. I 

aspiration a fluid is withdrawn which may be clear, or "I" a bron nisii 
colour, and recognised as urine by the facl thai it coi ba i and 

urea. After aspiration the urine passed per urethram may !><■ bloody. 
Aspiration affords only temporary relief, as the tumour quickly refills. I 
an incision is made and the kidney drained, a cure may result with tin- 
formation of a fistula. This may continue Indefinitely, or infection of 
the fistulous tract may occur and suppurative nephritis arhich 

46 



610 DISEASES OF THE URO-GEN1TAL SYSTEM. 

speedily carries off the patient. A better operation is nephrectomy, which 
may result in a permanent cure if the opposite kidney is healthy, which 
is usually the case if the child is over three years of age for the reason 
above stated, viz., that a child with malformation of both kidneys usually 
dies in infancy. Whether the other kidney is the seat of serious disease 
or not, will depend much upon how far advanced the changes are upon 
the side of the hydronephrosis. In most cases the sooner this condition 
is removed the better will be the outlook for the patient ; hence the ques- 
tion of operation should always be carefully considered. 

Supernumerary Ureters. — These were noted in four cases, more fre- 
quently on the left side. The usual deformity was for two ureters to be 
given off, one from the upper and one from the lower part of the kidney, 
each ureter having a separate pelvis. The ureters either joined just above 
the bladder, or entered this organ by separate openings. This condition 
is of no practical importance, and was not found associated with other 
renal changes. 

Malposition of the Kidney. — This was noted in my series of autopsies 
only once, in a case of fusion of the kidneys already mentioned. Of 
twenty-one cases collected by Eoberts, the displacement was always of one 
kidney only ; the left being displaced fifteen times, the right six times. 
Northrup has reported two cases, both displacements of the left kidney ; 
in one, the organ lay in the hollow of the sacrum ; in the other, in the 
median line, partly above and partly below the promontory of the sacrum. 
Malpositions of the kidney are compatible with perfect health and de- 
velopment. In most of the cases there is no other deformity present. 

Movable or Floating Kidney. — This is one of the rarest of the abnor- 
mal conditions seen in this organ in early life. Cases have, however, been 
reported by Phillips, Korsakow, and others, with symptoms similar to 
those seen in adult life. 

URIC-ACID INFARCTIONS. 

These consist in a deposit in the straight tubes of the kidneys of uric 
acid or of amorphous or crystalline urates ; usually both kidneys are af- 
fected, and all the pyramids of each kidney. The infarctions appear to 
the naked eye as fine, brownish, fan-shaped striae. Associated with them 
there may be granular deposits of uric-acid salts in the pelvis of the kidney, 
and sometimes evidences of catarrhal inflammation of the pelvis, including 
even the presence of blood. This condition probably occurs, to some de- 
gree at least, in nearly all infants during the first ten days of life. It was 
formerly supposed that the discovery of these appearances was proof that 
an infant had breathed, and a certain medico-legal importance was there- 
fore attached to them. This is now known not to be the case, as they are 
sometimes found in still-born infants. 

The cause of this condition is the excretion of uric acid before there is 



CHRONIC CONGESTION OF THE KIDNEY. QH 

sufficient water to dissolve it, so that the crystals are deposited in the 
tubes. Uric-acid infarctions are found chiefly in children dying before 
the end of the second week, although < it is not uncommon to see them as 
late as the third or fourth or even the sixth month. In most of the 
cases, as the urinary secretion becomes more abundant, the deposits are 
washed out in the urine and appear as brownish-red stains upon the nap- 
kins. Infarctions may give rise to a slight inflammation of the renal 
tubules, but very rarely to any serious lesion ; sometimes they remain as 
deposits in the calices or the pelvis of the kidney or in the bladder, form- 
ing the nucleus of a calculus. The symptoms to which they give rise are 
mainly scanty urination during the first week of life, and occasionally 
anuria for the first day or two. Sometimes there is evidence of pain on 
micturition, and there is the stain upon the napkin already referred to. 
The treatment is to give water freely and some alkaline diuretic such as 
citrate of potash. One grain should be given every two hours until the 
secretion is fully established ; this in most cases will be within twenty- 
four hours. 

ACUTE CONGESTION OF THE KIDNEY. 

In acute congestion of the kidney all its blood-vessels contain nineh 
more blood than normal, and from them there may be an escape of serum 
and even of the red blood-cells by diapedesis. This congestion may 
result from traumatism, the ingestion of certain poisons, from any of the 
infectious diseases, or from cold. 

The urine is usually scanty, of high specific gravity, and contains 
albumin and red blood-cells, sometimes blood casts. This may be onlj a 
temporary condition passing off in a few days without further Bymptoms, 
or it may exist as the first stage of acute nephritis. It is most serious when 
it occurs in kidneys already the seat of Berious disease. Then- are some- 
times no symptoms except those of the urine; or there may he headache, 
pain in the back, and some general indisposition. 

The treatment consists in free catharsis, the use of hoi vapour 
baths, and counter-irritation over the kidney- by means of hoi poultic* 
dry cups. 

CHRONIC CONGESTION OF THE KIDNEY. 

This results from interference with the return circulation of the leu 
ney, and maybe caused by congenital malformation or valvular i 
the heart, chronic broncho-pneumonia or chronic pleurisy j the 

pressure of any abdominal tun. our upon the inferior vnu cava or the 

renal veins. 

The kidneys are generally enlarged, firmer than normal, and dark- 
coloured. All the capillary vessels are Bwollen an. I distended with blood, 
and their walls are thickened. In addition to the Bymptoms of the pri- 



612 DISEASES OP THE URO-GENITAL SYSTEM. 

mary disease, the amount of urine passed is usually scanty and of high 
specific gravity. Albumin and casts are generally present, but are not 
constant. The treatment should be directed toward the primary con- 
dition, and, in addition, an effort should be made to increase the urine by 
alkaline diuretics, caffein, digitalis, and the sweet spirits of nitre. 



ACUTE DEGENERATION OF THE KIDNEYS. 

In the succeeding pages devoted to diseases of the kidney I shall fol- 
low the classification of Delafield, which seems to me the simplest and 
most exact that has yet been proposed. For the description of the lesions 
I am indebted largely to his Lectures. 

In acute degeneration of the kidney the principal or only change is in 
the epithelium of the tubules. It is exceedingly common both in infancy 
and in childhood, being found to a greater or less degree in all autopsies 
upon patients dying of acute infectious diseases, but it is most marked in 
cases of scarlet fever, diphtheria, and acute pleuro-pneumonia. It may 
be found in any disease characterized by prolonged high temperature ; and 
it is the explanation of the cases of so-called febrile albuminuria. The 
cause is in all probability direct irritation of the epithelium of the tubules 
by the toxines eliminated by the kidneys. It may also be induced by 
irritating drugs, such as cantharides or turpentine. By some writers these 
cases have been classed as examples of acute nephritis ; hence the great 
discrepancy which exists in statements made as to the frequency of 
nephritis in the different infectious diseases. 

The kidneys are usually slightly enlarged, and paler than normal. On 
section the cortex may be somewhat thickened, and the straight tubules 
marked by yellowish-gray lines. It is the appearance commonly spoken 
of as " cloudy swelling." The organs are seldom much congested. The 
microscope shows a granular degeneration and death of the epithelium 
of the tubules, and when severe this may be accompanied by congestion 
and the exudation of serum. 

Acute degeneration of the kidneys gives rise to no symptoms in addi- 
tion to those of the original disease, except the appearance of a moderate 
amount of albumin in the urine, and sometimes a few hyaline or granular 
casts. It can not be said that such a condition adds much to the danger 
of the original disease. In cases that recover, the condition of the kidney 
entirely clears up. The development of the symptoms of degeneration of 
the kidneys in infectious diseases calls for no special treatment beyond a 
continuance of the fluid diet. 



ACUTE EXUDATIVE NEPHRITIS. 013 



ACUTE EXUDATIVE NEPHRITIS. 

Synonyms: Acute parenchymatous nephritis, acute desquamative nephritis, acute 
septic interstitial nephritis. 

Etiology. — This variety of nephritis occurs apparently as a primary dis- 
ease both in infants and in older children. Most such cases are undoubt- 
edly of infectious origin, although the point of entrance of the infection 
it may be difficult or impossible to determine. This form of inflammation 
is much more frequently secondary to the acute infectious diseases, espe- 
cially to scarlet fever and diphtheria. It occasionally follows meat 
varicella, empyema, typhoid fever, acute diarrhoea! diseases, pneumonia, 
meningitis, influenza, and, in rare instances, eczema. This is the char- 
acteristic variety of secondary nephritis occurring in septic condition-. 
The exciting cause of the inflammation is in some case- the irritation 
from toxines ; in others there is in addition the entrance of pyogenic 
germs, carried by the circulation. 

Lesions. — This inflammation is characterized by congestion and exuda- 
tion of the blood plasma with leucocytes, and red blood-cells, also by 
changes in the renal epithelium and the glomeruli. In infants and yonng 
children the predominant feature of the lesion is usually the exudation of 
leucocytes. In severe cases the kidneys are enlarged, and usually sofl and 
(edematous. The cortex, which is the seat of the most marked chang 
thickened and of a uniform yellowish-white colour, or it may be mottled 
with red, owing to small haemorrhages. Sometimes there is congestion of 
the entire organ. At other times, both on the Burface and on section, the 
kidney presents a mottled yellow appearance, these yellow spots being 
aggregations of pus cells; they are scattered through the organ, and vary 
in size from a pin's head to a pea. Minute abscesses may even be found. 
The microscope shows the renal epithelium of the tubules to be Bwollen, 
loosened, and degenerated. The tubules may be dilated, and contain red 
and white blood-cells and degenerated epithelium. The glomerular chai 
are often marked. There are swelling and proliferation of the cells co 
ing the capillary tufts, and similar changes in the capillaries theraa 
There may be red or white blood-cells in the cavities of the capsules, and 
cocci may be found in the small blood-vessels. There are accumnlat 
of leucocytes in the tubes, in the stroma, and in the venous capi 
These cells are usually in irregular patches. The ition 

of leucocytes may not be accompanied by blood -•rum, and hence there 
may be no albumin in the urine. 

I have made autopsies upon Bis cases of nephritis of t\ in 

young infants, which were apparently primary. In all thi 
excessive exudation of leucocytes was the Btriking feature of the dia 



614 DISEASES OF THE URO-GENITAL SYSTEM. 

Under the microscope they were in places so dense as to obscure all the 
renal elements. 

Symptoms. — 1. Primary form in infants. — These cases are not com- 
mon, and the symptoms are so obscure that they are usually overlooked. 
In 1887 * I published five cases of my own, and collected from literature 
fourteen others of primary nephritis under two years of age. Since that 
time four additional cases have come under my observation. 

A study of these cases yields the following facts : The onset in nearly 
every instance was abrupt, usually with high fever and vomiting, the 
temperature being in several cases over 104° F. Dropsy was very excep- 
tional, being noted in but six cases ; in most of these it was slight, and 
seen only toward the close of the disease. Fever was present in all cases. 
In those observed by myself it was high and irregular in type, ranging 
from 101° to 105° F. The duration of the disease was from eight days 
to four weeks, the average being about two and a half weeks. Vomiting 
and diarrhoea were noted in half the cases, but were rarely prominent, 
and marked either the onset of the attack, or were traceable to indigestion 
accompanying the fever ; very rarely did they exist as symptoms of urae- 
mia. Anaemia was a prominent symptom in nearly every case, and it was 
this which enabled me in several instances to make a correct diagnosis. 
Nervous symptoms were usually prominent. In several patients there 
was dyspnoea without pulmonary disease, partly due, no doubt, to the 
anaemia. In nearly all cases there was marked restlessness or muscular 
twitchings, and in three there were convulsions. Dulness and apathy 
were present in the majority of the fatal cases, but deep coma was never 
seen. Several patients presented the typical symptoms of the typhoid 
condition. The urine was rarely scanty until near the close of the 
disease, and sometimes not even then. Suppression of urine occurred 
in but a few cases. Albumin was frequently absent early in the attack, 
but was invariably present at a late period, although rarely in large 
amount. Oasts were found in all cases that were carefully examined 
microscopically. They were not usually numerous, and were chiefly of 
the hyaline, granular, and epithelial varieties. No blood casts were seen. 
There were usually many pus cells and renal epithelial cells, together with 
red blood-cells in moderate numbers. 

Of the twenty-three cases, fifteen died and eight recovered. Of my 
own nine cases, eight were fatal, the diagnosis being confirmed by autopsy 
in every case but one. Whether these figures represent the actual mor- 
tality of the disease it is difficult to say. No doubt there are many mild 
cases which escape notice altogether. The severe ones, however, are quite 
uniformly fatal, chiefly on account of the tender age of the patients. 

2. Primary form in older children. — This also is a rare form of renal 
. ^ 

* Archives of Paediatrics, vol. iv, pp. 1, 103 ; and ix, p. 263. 



ACUTE DIFFUSE NEPHRITIS. 015 

disease. As compared with the same condition in infants, the onset is 
usually less abrupt, the febrile symptoms are less marked, and the termina- 
tion is less frequently fatal. There is little dropsy, often none at all. The 
urine is only slightly diminished in quantity ; the amount of albumin is 
small ; casts are not numerous, and usually hyaline, epithelial, or granu- 
lar; very rarely is there much blood present. Uraemia is very infrequent, 
and the prognosis is much more favourable than in infancy. 

3. Secondary form. — This is the most common variety of secondary 
nephritis of infectious diseases. It usually occurs at the height of the 
febrile process, and its severity is generally proportionate to the intensity 
of the infection. The constitutional symptoms are often not marked, and 
dropsy is rare. Unless the urine is examined the condition may be over- 
looked. The urinary changes are essentially the same as those already 
mentioned in the primary cases. While the involvement of the kidneys 
adds to the danger of the primary disease, it is rare that the nephritis is 
itself the cause of death. Suppression of urine and the development of 
the symptoms of acute uraemia are infrequent. 

ACUTE DIFFUSE NEPHRITIS. 
Synonyms: Acute Bright's disease, glomerulonephritis. 

This is a more severe form of inflammation than is exudative nephritis, 
and is much more likely to be followed by permanent damage to the 
kidney. 

Etiology. — Acute diffuse nephritis occasionally occurs in children ap- 
parently as a primary disease, its origin being then obscure. It is usually 
attributed to cold and exposure, and certainly this is sometimes the 
It is the secondary form which is especially important in early life, and in 
the great majority of cases this follows scarlet fever. It is tin- characteris- 
tic post-scarlatinal nephritis. Occasionally, however, it follows diphtheria, 
and may indeed occur after any severe form <>f infections disease. Tie- 
cause in the scarlet-fever cases is now generally admitted to be the po 
of the primary disease— probably the result of direct irritation from 
ines. While it may sometimes iolh.w a definite exposure, as when patients 
have been allowed to get up or go out too soon, it occurs also in I 
who have been kept in hed throughout the attack; sometimes even in mi 
cases. But there is little doubt that exposure may precipitate an al 
in a patient who might otherwise haveesoaped. An im] 
factor is the too early use of solid food. The frequency of nephritu 
sequel of scarlet fever varies much in differenl epidemi 
rarely seen, while in others it may occur in nearly half I 
average is probably from six to ten per cent. While it m< ently 

follows a severe form of Bcarlel fever, it ma 
which has been so mild as to escape notice until the appearand 



616 DISEASES OF THE URO-GENITAL SYSTEM. 

desquamation. Season appears to have but little influence upon its 
frequency. 

Lesions.— In this form of inflammation most of the changes of acute 
exudative nephritis are present, but in addition there are marked altera- 
tions in the stroma of the kidney and the Malpighian bodies. The kid- 
neys are enlarged, often considerably so, and appear rather soft and flabby. 
In the early stage they are sometimes much congested ; later, they are of 
a yellowish-white colour with a fine red mottling. The cortex usually 
appears much thickened and yellow, while the pyramids are red. The 
characteristic lesions of this form of nephritis are a production of con- 
nective-tissue cells in the stroma, and proliferation of the cells forming 
the capsules of the Malpighian bodies. These changes usually occur in 
patches. In recent cases there are found only the new connective-tissue 
cells ; in older ones the connective tissue is more dense and even fibrous 
in character. The changes in the glomeruli may be permanent, the tufts 
being compressed by the growth of the endothelial cells lining the cap- 
sules, which may ultimately form new fibrous tissue. 

Symptoms. — When the disease is primary, it may begin abruptly with 
febrile symptoms, dropsy, headache, lumbar pains, scanty urine, and often 
with vomiting ; or it may come on somewhat insidiously with few consti- 
tutional symptoms, but with dropsy and changes in the urine. When it 
follows scarlet fever it most frequently develops during the third or fourth 
week of the disease. The onset is usually gradual, with dropsy, scanty 
urine, and moderate fever. The subsequent course may be the same in 
both the primary and secondary cases, whatever the mode of onset. 

There is in most cases some fever; usually the temperature ranges 
from 100° to 101-5° R, but in very severe attacks it may be 104° or 105° 
F. Dropsy is almost invariably present, and is generally marked. It is 
first seen in the face, next in the feet, legs, and scrotum, and there may 
be general anasarca, with dropsy of the serous cavities of the body ; this 
is usually of the pleura or the peritonaeum, rarely of the pericardium. 
As the disease progresses there is always a very marked degree of 
anaemia. 

The urine is, as a rule, greatly diminished in quantity, and may be 
suppressed. Albumin is invariably present, and usually in large amount, 
often enough to render the urine solid upon boiling. The urine is of a 
dark, reddish-brown or smoky colour, owing to the presence of red blood- 
globules or haemoglobin. The amount of urea eliminated is far below the 
normal. The specific gravity may be low, even though the quantity is 
very small. Casts are present in great numbers — chiefly hyaline, gran- 
ular, and epithelial casts from the straight tubes ; not infrequently there 
are blood casts. Occasionally twisted or cork-screw casts are seen. These 
come from the convoluted tubes, and are regarded by Ripley (New York) 
as of grave significance, indicating that all parts of the kidney are 



ACUTE DIFFUSE NEPHRITIS. 617 

involved. Eed blood-cells are present in great numbers; also many 
leucocytes, and always a large amount of renal epithelium. 

The duration of the active symptoms in cases terminating in recovery 
is from one to three weeks. The temperature and dropsy gradually sub- 
side. Improvement in the urine is shown by an increase in quantity, by 
increased elimination of urea, and by a diminution in the amount of 
blood, albumin, and the number of casts. A few casts may persist for 
several weeks, and a small amount of albumin for two or three months. 

In the graver cases, where the onset is accompanied by high temper- 
ature, pain in the back and loins, and a rapid, full pulse of high tension, 
the urine is very scanty and is often suppressed. Then follow the symp- 
toms of ura3mia. In children this is usually manifested by vomiting, 
great restlessness or apathy, and often by diarrhoea. Less frequently 
there are headache, dimness of vision, stupor developing into coma, or con- 
vulsions. If the secretion of urine is re-established, the nervous Bymptoma 
abate and the patient may recover. This has been known to occur after 
complete suppression has lasted thirty-six hours. Care should be taken 
not to mistake retention for suppression. If doubt exists, percussion of 
the bladder and the use of the catheter will quickly settle the question. 

There are several complications for which the physician must con- 
stantly be on the lookout during attacks of acute nephritis; the mosl 
frequent are pneumonia, pleurisy, pericarditis, and endocarditis; more 
rarely there maybe meningitis and oedema of the glottis. It is from com- 
plications or acute uraemia that death usually occurs. 

Prognosis. — This is to be considered from two points of new: first, 
the dauger to life during the acute stage of the disease, and, secondly, the 
danger of the development of chronic nephritis. The great majority of 
patients survive the acute stage, and not infrequent lv eveu those recover 
who have presented grave symptoms of uraemic poisoning. The quantity 
and specific gravity of the urine, and the number and variety of the i 
are a much better guide in prognosis than the amount of albumin. The 
existence of severe nervous symptoms, Buch as stupor, intense headache, 
dimness of vision, and persistent vomiting, add much to the gravity of 
the case, as does also the presence of any serious complication. In gen- 
eral it may be said that if there is no suppression of urine, or if there are 
no symptoms of uraemia and no complications, recovery i^ almosl certain 
if the child is over three years old ; in younger children the outlook u 
favourable. The general opinion prevails that acute diffuse uephriti 
childhood, whether it is primary or occurs as a complication of 
fever, is rarely followed by the chronic form of the disease; and Buch 
the view I formerly held. Larger experience, however, I "'«• 

that this sequel is not very uncommon. Tie- interval of apparent health 
may sometimes cover a period of several ad the later nepb 

may be attributed to other causes; but all arlatmal ne- 

47 



618 DISEASES OF THE URO-GENITAL SYSTEM. 

phritis should be carefully watched for a long time, and after a severe 
attack a guarded prognosis should always be given as regards the ultimate 
result.* 

Treatment of Acute Nephritis. — Prophylaxis is important, and relates 
principally to the secondary form which occurs in the course of infectious 
diseases, especially post-scarlatinal nephritis ; f but the measures here out- 
lined apply equally to all varieties. The inflammation of the kidney being 
in most of these cases the result of direct irritation by the toxines which 
are eliminated by them, it follows that elimination through the skin and 
intestines should be increased, and that the urine should be rendered as 
little irritating as possible by largely increasing its quantity. The first 
indication is met by frequent sponging, warm baths, and keeping the 
bowels freely opened by saline cathartics, sufficient being given to produce 
one or two loose movements daily. To meet the second indication, the 
patient should be kept upon a fluid diet, preferably milk, at least' for 
the three weeks of the disease, and, if possible, for a full month. At the 
same time he should drink very freely of alkaline mineral waters, or of 
plain water to which a small dose (two or three grains) of some alkaline 
diuretic like the citrate of potassium has been added. If milk is not well 
borne, kumyss, whey, buttermilk, or junket may be used, or thin gruels 
mixed with milk. When the first trace of albumin appears in the urine 
this plan of treatment should invariably be followed. In addition to these 
measures, after an attack of scarlet fever the patient should ~be kept in bed 
for at least a week after the temperature has become normal. 

The mild cases of acute nephritis tend to spontaneous recovery under 
the hygienic and dietetic treatment mentioned — i. e., rest in bed, fluid diet, 
the drinking of large quantities of water, and attention to the action of 
the skin and bowels. These measures should be continued so long as 
the urine contains any considerable amount of albumin, or so long as the 
patient's general condition will permit. Should he become very anaemic, 
or lose much in weight, it may be necessary to enlarge the diet by the 
addition of solid food. This should at first be of the carbohydrates only, 
usually in the form of some farinaceous food. An increase in the diet 
and exercise should be made very gradually, and the effect upon the 
urine carefully watched. 



* The following case may be cited as an illustration of this point : A girl at the age 
of seven years had scarlet fever, followed by nephritis ; the dropsy having lasted, it 
was reported, for three months. She was believed to have recovered perfectly, and 
remained in apparent health until she was sixteen, when, as a supposed result of a 
severe chilling, she developed dropsy and all the symptoms of acute nephritis. From 
that time, although she lived for three years, and was often for months at a time 
seemingly in the best of health, her urine was never free from casts and albumin, and 
she finally died in uraemic convulsions. 

\ See W. II. Flint, New York Medical Journal, January 6, 1894. 



CHRONIC NEPHRITIS. 519 

The severe cases, with scanty urine, fever, and marked dropsy, require 
more active treatment. Free diaphoresis should be maintained by the 
hot pack or vapour bath (page 54), and in bad cases even pilocarpine may 
be used hypodermically, a dose of gr. -^ being given to a child of three 
or four years. To counteract the depressing effects of this drug, stimu- 
lants should be given at the same time. Active counter-irritation should 
be maintained over the kidneys by dry cups followed by poultices, or 
the mustard paste. Two or three loose movements from the bowels should 
be secured by the administration of calomel, or, better, by Rochelle, or Ep- 
som salts. Harm is sometimes done by carrying this depletion too far, and 
its effect upon the patient's general condition must be closely watched. If 
suppression of urine occurs with the development of uraemic symptoms — 
delirium, high temperature, flushed face, vomiting, and a pulse of high 
tension — nitroglycerin maybe given; a child of five years may take gr. 
-i^ every hour for three or four doses, or until an effect is produced. 
Uraemic convulsions may often be averted by the use of morphine hypo- 
dermically; but if the symptoms are very urgent, nothing is so rapid or 
so certain to give relief as venesection. This has lately hem revived in 
the practice of Kew York physicians, and has now the indorsement of the 
best practitioners in the city. From a child of five years from two to Bix 
ounces of blood may be taken, according to the general condition and the 
urgency of the symptoms. Even though the improvement which follows 
bleeding under the conditions mentioned is very certain, it is often only 
temporary; but it gives time for the use of other measures, such as 
tharsis and diaphoresis. The depressing effects may be largely overcome 
by following the venesection by an intravenous injection of a saline solu- 
tion (^r. iv to water § j). The amount introduced should be nearly twice 
that of the blood taken. 

One should always be on the lookout for complications, especially 
dropsy of the serous cavities, pericarditis or endocarditis, and oedema of the 
lungs. Convalescence is nearly always slow, and a patient who has suf- 
fered from nephritis needs careful attention for a long time. Ansemia is 
always present, and iron is required. The diet musl consisl largely of 
fluids for several months. If the disease tends to pass into a Bubacute 
form, the child should, if possible, be sent to a warm climate, and kept 
there during the succeeding winter, and every means taken to buildup 
the general nutrition. Flannels should be worn next t«» the , kin. and 
every precaution taken a-ai nst any exposure which mighi ca 
bation of the disease. 

CHRONIC NEPHRITIS. 

Chronic inflammation of the kidney is an infreq >n in 

childhood. In infancy it is almost unknown. tion with 

congenital hydronephrosis or other malformations of I •• Two 



620 DISEASES OF THE URO-GENITAL SYSTEM. 

pathological varieties are met with : (1) Chronic diffuse nephritis with 
exudation, known also as the large white kidney, chronic parenchyma- 
tous nephritis, and waxy kidney. (2) Chronic diffuse nephritis without 
exudation, known also as interstitial nephritis, granular kidney, and con- 
tracted kidney. 

Etiology. — Chronic nephritis is most frequently seen as a sequel of the 
acute nephritis of scarlet fever. It also occurs with the prolonged 
suppuration of chronic bone or joint disease, where it may be chronic 
from the beginning. The only other important causes in early life are 
hereditary syphilis, alcoholism, chronic tuberculosis, and valvular disease 
of the heart. Nearly all the cases occur in children over seven years 
of age. 

Lesions. — The lesions of chronic nephritis in childhood do not differ 
essentially from those seen in later life. In chronic diffuse nephritis 
with exudation, the kidneys are usually enlarged, the surface is smooth 
or slightly nodular, and yellowish-white on section. The microscope 
shows that the renal epithelium is swollen, granular, fatty, and degen- 
erated. The tubes contain cast-matter and the detritus of broken-down 
epithelial cells. In some places they are dilated,. in others atrophied. In 
the glomeruli there is a growth of capsule cells, compression and atrophy 
of the tufts, with the formation of new connective tissue. When there is 
waxy degeneration, the kidneys are usually considerably enlarged, and of 
a glistening gray colour. Amyloid degeneration is seen especially in the 
small arteries of the kidney and the capillary vessels of the tufts. With 
iodine the mahogany-brown reaction is obtained. Amyloid changes in 
the kidney are nearly always associated with similar lesions in the liver 
and spleen, and sometimes also in the intestinal villi. 

In the chronic diffuse nephritis ivithout exudation (granular kidney) 
the organs are smaller than normal, with a nodular surface and adherent 
capsule. The cortex is thinned, and the colour is gray or red. In addi- 
tion to the lesions found in the preceding variety, there is an extensive 
production of new connective tissue, which is irregularly distributed 
throughout the kidneys. The tubules in some places are dilated to form 
cysts of considerable size, while in others they have completely disap- 
peared. The glomeruli may be atrophied to little fibrous balls, but if 
chronic congestion has preceded the inflammation, they may be large and 
the capillaries dilated. 

Symptoms. — 1. Chronic nephritis with exudation. — This form of dis- 
ease is not usually chronic from the outset, but follows an acute attack 
from which the patient is often supposed to have recovered completely. 
The symptoms sometimes immediately follow the acute attack ; at others 
there is an interval of apparent recovery, extending over a few months or 
even years. Very rarely no such history of an antecedent acute attack can 
be obtained, and the symptoms come on gradually and insidiously. Such 



CHRONIC NEPHRITIS. tlLM 

cases occur chiefly in older children, and their clinical features do not 
differ essentially from those of adult life. 

As a rule dropsy is present, although it is variable in amount, and fluc- 
tuates considerably from time to time. There may be not only oedema of 
the cellular tissue, but effusion into the pleura, peritonaeum, and even the 
pericardium. As the case progresses, anaemia is always a marked symp- 
tom. There are various disturbances of digestion — loss of appetite, occa- 
sional vomiting, and attacks of diarrhoea. From time to time nervous 
symptoms may be quite prominent, such as headaches, sleeplessness, neu- 
ralgia, fatigue upon slight exertion, and dyspnoea. Attacks of epistaxis 
are not infrequent. 

The urine contains albumin and casts nearly all the time. They vary 
much in amount at different periods in the disease, according to the 
rapidity of its progress. During periods of exacerbation, both albumin 
and casts are very abundant, while in the intervals the amount of albumin 
is small and the casts few. The casts are hyaline, granular, epithelial, and 
fatty. The daily quantity of urine is much reduced during the periods of 
exacerbation, while at other times it may be nearly normal. The Bpecific 
gravity is usually low. 

If waxy degeneration is present, there are generally associated with the 
renal symptoms, others dependent upon waxy changes in other organs. 
The spleen and liver are enlarged ; there maybe ascites and diarrhoea, and 
there is usually present the peculiar "alabaster cachexia." 

The duration of this form of chronic nephritis depends much upon tin- 
surroundings of the patient and the treatment. It is rarely shorter than 
two years, and it may last for many years. The progress is always Irregu- 
lar, and marked by periods of exacerbation and remission. The patii 
die from acute uraemia, or from complicating pneumonia, pleurisy, peri- 
carditis, endocarditis, or from pulmonary oedema 

2. Chronic nephritis without exudation.— This is a very rare disease 
in early life, being much less frequent even than the preceding variety of 
nephritis. In some cases there is a history of hereditary Byphilis; in 
others, of chronic alcoholism. The early symptoms are few, and the dis- 
ease usually develops insidiously. The urine is pair, excessive in amount, 
and of low specific gravity— 1 00 1 to L-008. Albumin is more often 
absent than present, and, when found, the quantity is small. Dropsy 
likewise is rare, and never marked. Nervous symptoms are often prom- 
inent, such as headaches, attacks of spasmodic dyspnoea resembling 
asthma, neuralgias, and disturbances of vision. High arterial tension 
and hypertrophy of the left ventricle are regular Bymptoms; and even 
atheromatous degeneration of the arteries may be present Dickii 
reports an instance of this in a patienl only sis . 
the disease, haemorrhages may occur, and these may be the 
death. Filatoff has reported a cerebral haemorrhage in a child of eleven. 



Q22 DISEASES OF THE TJRO-GENITAL SYSTEM. 

Acute uraemia is, however, the usual termination of this form of nephritis. 
The course is slow, and the disease may be overlooked until the final 
uraemic symptoms occur. 

Prognosis. — The prognosis of chronic nephritis as to complete recovery, 
is always unfavourable ; and although cases are seen in which symptoms 
are absent for several years, they almost invariably return. Oases have 
been reported of recovery from waxy degeneration of the kidney after 
removal of the bone disease upon which the condition depended. Al- 
though symptoms may be absent for a long time, complete recovery is very 
doubtful. An extended period of observation is necessary before the pa- 
tient can be pronounced cured. As to the duration of the disease, no exact 
prognosis can be given because, from the symptoms, it is difficult or im- 
possible to determine exactly the extent of the disease in the kidney and 
the rapidity of its progress. According to Delafield, the continued pas- 
sage of a large amount of urine of low specific gravity is invariably to 
be interpreted as evidence of fibroid changes in the Malpighian tufts, 
and is a bad symptom. A large amount of dropsy, the coexistence of 
valvular disease of the heart, and marked renal insufficiency, as shown 
by a quantitative examination of the urine, are all very unfavourable 
symptoms. 

Diagnosis. — Chronic nephritis like the acute forms is likely to be over- 
looked because of the failure to examine the urine in children. Regular 
and frequent examinations should be made in all cases of convulsions, of 
persistent or frequent headaches, severe anaemia, hypertrophy of the heart, 
high arterial tension and of general malnutrition, as well as when the 
more obvious symptoms of renal disease, such as dropsy and scanty urine, 
are present. Nor should one be too ready to make the diagnosis of func- 
tional albuminuria because he finds albumin only occasionally and in 
small quantity. All such cases demand most careful observation and the 
closest attention for a long period before excluding organic renal disease. 

Treatment. — Children with chronic nephritis are to be treated on the 
same general plan as adults. The purpose of treatment is to retard as 
much as possible the progress of the disease and to relieve the symptoms 
as they arise. It is of the greatest importance to remove the patient from 
conditions in which exacerbations are liable to occur. If it is possible, 
he should be sent to a warm, dry climate in winter, and all exposure 
to cold avoided ; an out-door life is desirable. Most patients require a 
general tonic treatment with very moderate but regular exercise, never 
carried to the point of fatigue, as much rest as possible in a recumbent 
position, a fluid diet, consisting largely of milk as long as this can be 
borne, and the administration of iron, particularly the tincture of the 
chloride. Excessive dropsy calls for diuretics, saline cathartics, and heart 
stimulants. If uraemia develops, with high arterial tension and stupor, 
headache, and convulsions, venesection should be resorted to, or nitro- 



MALIGNANT TUMOURS OF THE KIDNEY. £03 

glycerin used. Morphine may be given hypodermically if the pupils are 
dilated and nervous symptoms are very marked. 

TUBERCULOSIS OF THE KIDNEY. 

In general tuberculosis, miliary tubercles are frequently seen both upon 
the surface of the kidney and in its substance. These give rise to no 
symptoms and are of no clinical importance. Larger tuberculous deposits 
are extremely rare in early life. They usually occur in patients who are 
the subjects of general tuberculosis, and are associated with tuberculosis 
of other parts of the genito-urinary tract ; or they may exist as the pri- 
mary, and even the only, tuberculous lesion in the body. At least two 
such cases are on record in children, one reported by West and the other 
by Rilliet and Barthez. Infection of the kidney generally takes place 
through the circulation, and not from the bladder. Aldibert's figures 
show that in children the bladder usually escapes even when the kidneys 
-are tuberculous, for of thirteen cases of renal tuberculosis the bladder 
was involved in but two. The ages of twelve of these patients were as fol- 
lows : from two to four years, four cases ; from seven to eleven, five ci 
from eleven to fourteen, three cases. The disease probably begins in the 
mucous membrane of the pelvis and the calices of the kidney, and extends 
to the pyramids, finally involving the cortex. As a rule, but one kidney 
is affected. The process may be confined to the pyramids, where are 
found cheesy nodules which may be single or multiple. These ultimately 
break down and form abscesses. The process may result in almost com- 
plete destruction of the pyramids, and even of portions of the corte 
that the kidney may consist of a mere shell of renal tissue. Suppuration 
in the neighbourhood of the kidney (perinephritic abscess) often coexists. 

The symptoms are quite indefinite. There may be localized pain and 
tenderness in the region of the kidney, and a tumour if there is perine- 
phritis. The symptoms of irritability of the bladder may be almost 
severe as in cases of calculus. Pus appears in the urine usually aa a 
constant symptom ; but the only thing thai is diagnostic ia the discovery 
of tubercle bacilli in the urine. 

The treatment of renal tuberculosis la purely surgical. 01 the thirteen 
cases collected by Aldiberl in which nephrectomy was done for this con- 
dition, there were nine recoveries and four deaths, two of the deaths, 
however, not being traceable to the operation or to the original di» 
No recurrence had taken place in one case at the end of eighl years, and 
none in another after three years. 

MALIGNANT TUMOURS OF THE KIDNEY. 
In the great majority of cases tumours of the kidney are malignant 

Of fifty-one cases collected by Aldibert which were operated upon, forty- 
eight were malignant and three benign. 



624 DISEASES OP THE URO-GENITAL SYSTEM. 

Malignant growths are almost invariably primary. In children under 
five years, although not common, they are yet more frequent than any other 
variety of malignant tumour of the abdomen. The earlier cases reported 
were classed as carcinoma. It is now well established that carcinoma is 
very infrequent, and that nearly all the cases are varieties of sarcoma. 
Fischer reports nineteen of sarcoma and two of carcinoma ; Aldibert, 
thirty-eight of sarcoma and five of carcinoma. The sarcoma may be 
round- or spindle-celled, or myo-sarcoma. In some of the cases there are 
both sarcomatous and carcinomatous features, so that they might be 
classed as sarcomatous carcinoma. The tumour grows from the cortex 
of the kidney, or from the pelvis, sometimes from the adrenals. It may 
infiltrate the whole kidney, so that there is no trace of renal structure re- 
maining, or it may form an immense tumour on one side of the kidney, 
which is only partially invaded. These tumours are very rarely cystic, 
but they are quite soft, and haemorrhages often occur iuto their sub- 
stance. Secondary growths may occur in the liver, the lungs, the retro- 
peritoneal glands, in the opposite kidney, in the intestines, or in the 
pancreas. Pressure of the tumour upon the ureter may lead to hydrone- 
phrosis ; and upon the inferior vena cava, to thrombosis of that vessel. 
As it grows, the tumour sometimes becomes adherent to nearly all the 
abdominal organs by localized peritonitis. It may lead to ascites, but 
it very rarely causes general peritonitis. The growth may reach a great 
size, usually from five to fifteen pounds, but in one case reported by 
Jacobi it weighed thirty-six pounds. In Seibert's collection of 48 cases 
the right kidney was involved in 24, the left in 22, and both kidneys in 
2 cases. 

Etiology. — These tumours of the kidney may be congenital. This 
was true of 5 cases in a series of 55 collected by Jacobi. The major- 
ity occur in early childhood. In the collection of 130 cases by Long- 
street Taylor in which the ages are given, 106 were in the first five 
years, and 57 of these in the first two years of life. The sexes were 
about equally affected. In a small number of cases the history of a fall 
was given. 

Symptoms. — The principal symptoms are tumour, hematuria, and 
cachexia. The tumour is usually first noticed. It is in most cases dis- 
covered in the loin, but grows forward toward the median line. Its 
surface may be lobulated and irregular or quite smooth ; and although 
solid, it is sometimes so soft as to give an obscure sensation of fluctua- 
tion. It may grow to an enormous size, causing displacement of the 
liver, spleen, intestines, and lungs. The progress of the growth is usu- 
ally rapid, so that from the size of a fist, the tumour may grow in the 
course of three or four months so as to fill the abdomen. By careful 
palpation it will be found — certainly when the tumour is small — that 
although it may be quite freely movable, its attachment is near the lum- 



MALIGNANT TUMOURS OF THE KIDNEY. 

bar spine. Aspiration may show blood, but more frequently the result 
is negative. 

Hematuria was observed before the tumour in 19 of 50 cases (Seibert), 
it being then the first symptom noticed. The amount of blood passed 
is sometimes quite large, but is usually small, and may be discovered 
only by the microscope. Pain is rare, and is due to localized peritonitis. 
Constitutional symptoms are absent until the tumour has attained a large 
size, when a cachexia develops and the patient wastes steadily while the 
tumour continues to grow. The pressure effects are dyspnoea, from com- 
pression of the lungs; oedema of the lower extremities, from pressure 
upon or thrombosis of the vena cava; vomiting and indigestion, from 
pressure upon the stomach and intestines. Secondary deposits very rarely 
cause any symptoms except in the lungs, where they may give rise to 
cough, and even to haemoptysis. 

The course of the disease is steadily from bad to worse. The usual 
duration of life in patients not operated upon, is from three to ten months 
after the tumour is discovered ; very rarely do they live a year, death 
usually occurring from exhaustion. 

Diagnosis. — The diagnosis of sarcoma of the kidney is usually quite 
easily made from the position and attachment of the tumour, its rapid 
growth and solid character, the existence of hematuria, and the age of 
the patient (under five years). It may be confounded with hydronephro- 
sis, dermoid cyst of the ovary, enlargement of the spleen, retro-peritoneal 
sarcoma, tumours of the liver, or even of the abdominal wall. 

Treatment. — Nothing is to be said regarding the medical treatment of 
these cases. Unless operated upon, I believe they invariably terminate 
fatally. The results of operation during recent years have been so en- 
couraging that no case should be abandoned, no matter how young the 
patient. Aldibert has collected the results of forty-live cases operated 
upon: twenty deaths occurred soon after the operation, two thirds of 
them from shock; in eleven cases recurrence of the growth occurred 
within nine months, and caused death. This raises the total mortality to 
78 per cent. Recently, in the Babies' Eospital, two cases have been 
successfully operated upon by my colleague, Dr. Robert Abbe; one. a 
nursing child, thirteen months old, where the tumour weighed seven 
pounds, and the child after the operation only fifteen pounds. Thi 
made an uninterrupted recovery, and three years after the operation was 
in perfect health. The accompanying illustrations (I'm- L06 and L07) 
are from photographs of this patient. The second case was in a child 
two years old, and the tumour weighed two and a quarter pounds, 
child made an excellent recovery, and was in perfect health three.] 
and nine months after the operation. These results certainly are en- 
couraging, and show conclusively that infancy is DO contraindication to 
the operation. 





626 



PYELITIS. do; 

For a discussion of the surgical aspects of this question, and details 
of the operation, see the papers of x\bbe * and Aldibert.f 

Benign Tumours. — These are distinguished by their slow growth, and 
by the fact that the constitutional symptoms are mild or wanting. I I 
the three cases collected by Aldibert, one was adenoma, one fibroma, and 
one was fibro-cystic. Two cases recovered, and one died of septic peri- 
tonitis. The duration of the disease was from twenty months to six years. 

PYELITIS. 

Pyelitis is an inflammation of the mucous membrane lining the pelvis 
of the kidney. It may exist alone, or with an inflammation of a portion 
of the ureter, or of the kidney itself (pyelo-nephritis) ; and it may be acute 
or chronic. It may result in an accumulation of pus in considerable 
quantity in the pelvis of the kidney (pyonephrosis). 

Etiology. — Of local causes, the most frequent is irritation from renal 
calculi. It is also associated with congenital malformations of the kid- 
neys or ureters, with renal tuberculosis and renal tumours. It may 
result from an extension of inflammation from the tissues surrounding 
the kidney (perinephritis), or from an abscess opening into the pelvis of 
the kidney. The secondary pyelitis, which so often follows cystitis in 
adults, is an extremely rare occurrence in childhood. In addition to the 
forms mentioned, there is seen an infectious form of acute pyelitis, which 
usually occurs as a complication of scarlet or typhoid fever, diphtheria, 
malaria, or pyemia ; but it is also seen apart from these diseases, when it 
occurs apparently as a primary affection. I have seen in infants three 
cases of this description. In this group of cases the infection [a probably 
through the circulation, but in the cases which occur independently <>f 
the acute infectious diseases it may be impossible to determine the point 
of entrance of the infection. In most, if not all the- cases there is 
also present a certain amount of nephritis. 

Lesions.— When pyelitis develops from a local cause it is nsuallj uni- 
lateral. In the infectious form both kidneys are involved. In the acute 
cases there are the usual appearances of an acute catarrhal inflammation 
of the mucous membrane, with congestion, swelling, and Borne! 
minute hasmorrhages. In chronic cases there is thickening and some- 
times a granular condition of the lining membrane. There maj be an 
accumulation of pus of considerable rize, distending the pelvis and ea 
(pyonephrosis). If the condition is one depending upon a calcul ^con- 
genital deformity, and in all protracted and Bev< , the kidnej itaelf 
is involved to a greater or less degree; tie' extenl of the nephritis will de- 
pend upon the nature of the exciting cause and the duration of th< 



* Annals of Surgery, January, 1894 

f Revue Mensuelle des Maladies de L'Bnfanoe, N ivemb i 



628 DISEASES OP THE URO-GENITAL SYSTEM. 

Symptoms. — The history of the following case illustrates the main 
clinical features of acute infectious pyelitis, in this instance occurring 
apparently as a primary disease : 

A previously healthy female infant of eight months was taken sud- 
denly with a chill, followed by a very high fever. The child was ill for 
ten days before the nature of the disease was suspected. During this 
time the temperature ranged between 101° and 106° F., touching 105° 
nearly every day; but the chill was not repeated. The other constitu- 
tional symptoms were not severe. At the first examination of the urine 
there was found a large amount of pus, which on standing was equal to 
one twelfth of the volume of the urine passed ; the reaction was strongly 
acid. There were no signs of vaginitis or vulvitis, no ardor urince, no 
evidence of local pain either in the bladder or kidney, no abnormal fre- 
quency of micturition, no localized tenderness, and no vomiting. At 
later examinations there were found in moderate numbers epithelial cells 
from the bladder, and the tubules and pelvis of the kidney, also a few 
hyaline casts, but not more albumin than would be explained by the 
amount of pus. Under no treatment except alkaline diuretics, the tem- 
perature gradually fell to normal and the pus steadily diminished in 
quantity, and at the end of five weeks had practically disappeared from 
the urine. A report sixteen months later stated that the child had re- 
mained well and entirely free from urinary symptoms. 

In some cases there are recurring chills, with wide fluctuations in 
temperature ; in others there may be only pyuria, with moderate fever 
and few other constitutional symptoms. If the disease complicates one of 
the acute infectious diseases, pyuria may be the only symptom. The 
urine in acute pyelitis is turbid from the presence of pus, the amount 
of which may be from one to fifty per cent of the volume of the urine. 
The quantity of urine is generally somewhat diminished, and it may be 
quite scanty. The reaction is usually acid, even though the amount of 
pus is large. Albumin is present in proportion to the amount of pus or 
the degree of nephritis. Red blood-cells are found under the microscope 
in most of the very acute cases, and may be in sufficient numbers to 
colour the urine. The pus cells in recent cases are usually well preserved, 
but in old cases they may be degenerated. There are many epithelial 
cells — conical, fusiform, and irregular cells with long tails. There may 
be renal epithelium and hyaline, granular or epithelial casts, varying in 
number with the severity of the nephritis. Bacteria also are found in 
great numbers. 

In chronic pyelitis only pyuria may be present, or there may be a 
tumour owing to the pyonephrosis. From time to time in the chronic 
form there may be intermittent attacks of acute pyelitis resembling those 
above described. In pyelitis depending upon congenital malformations, 
pyuria is usually the only symptom, unless pyonephrosis is present. With 



PYELITIS. 629 

calculi we may have acute or chronic pyelitis; there may be Localized 
pain, tenderness, sometimes a tumour, occasionally hematuria, and per- 
haps a history of renal colic or the passage of gravel. With tuberculosis 
we have chronic pyuria and the presence of tubercle bacilli in the urine. 
There are commonly associated the symptoms of general tubercul 
If associated with perinephritis, the inflammation is usually acute, and 
there are present the local symptoms of the original disease. If an ab- 
scess opens into the pelvis of the kidney we may have a sudden dis- 
charge of pus in large quantity with a subsidence of previous local symp- 
toms, including the tumour. With neoplasms we have congestion and 
haemorrhage more frequently than pus, but both may be present 

Diagnosis. — The characteristic symptoms of acute pyelitis are a eh ill, 
which may be repeated, high and fluctuating temperature, scanty urine, 
frequently pain and tenderness over the kidneys, and pyuria. The diag- 
nosis of pyelitis is made only by an examination of the urine, which 
should never be omitted in cases of obscure high temperature, even in 
infancy, particularly if chills are associated. Given the existence of a 
large amount of pus in the urine, it maybe difficult to decide whether 
this comes from the bladder or the kidney. Pus from the bladder ie 
ceedingly rare in children even when a vesical calculus is present. If tin- 
pus comes from the opening of an abscess into the bladder, ureter, or pelvis 
of the kidney, the local signs of such abscess will usually he present The 
existence in an acid urine of a large amount of pus, many epithelial cells 
like those described, with high fever and chills, arc generally sufficient 
to establish the diagnosis of pyelitis. 

Prognosis. — In cases apparently primary, and in those complicating 
infectious diseases, the prognosis is good. The danger is chiefly from 
the nephritis which follows or complicates the process. In cases <\<- 
pending upon local conditions, the prognosis will depend upon the 
nature of the exciting cause. Here, also, the principal danger is from 
nephritis. If calculi are presenl ami if pyonephrosis develops, the 
patient may die from exhaustion before a serious degree of nephritis 
developed. 

Treatment.— In all cases the diet should he fluid. Water should be 
given freely, and alkalies up to the point of neutralizing the • 
acidity of the urine. In infants, from twelve to twenty-four -rams of the 
citrate of potash are required daily for this purpose. If the nrine is alkaline, 
benzoic acid may be used in the same doses. In acute caa -. counter- 
tationover the kidney by means of poultices or dry cup. may beemplo 
If calculi are present the same treatment is indicated. Surgical interfer- 
ence is called for if pyonephrosis develops, or if the di 
unilateral and the kidney is becoming disabled. Tl 
surgical interference will depend upon the cle sveritj "f tin- 

symptoms. 



630 DISEASES OF THE URO-GENITAL SYSTEM. 



RENAL CALCULI. 

Small renal calculi are very common in infancy. In the autopsy- 
room of the Babies' Hospital we frequently see, on opening the kidneys 
of young infants, fine brown granules in the pelvis and calices, and oc- 
casionally a calculus as large as a small pea is found. They are usually 
composed of uric acid. Only once in over one thousand autopsies of 
which I have records, was a stone of any considerable size seen in an in- 
fant. In this case it was an inch in length and half an inch wide. It is 
surprising that these are so rare, when we consider how very frequently 
the minute calculi are met with. The probable explanation is, that the 
majority of them have been dissolved or washed down into the bladder 
and passed per urethram because of the fluid diet of the first two years. 
The granular deposits are usually lodged in the pelvis of the kidney, and 
are generally seen upon both sides. With the larger collections there is 
often a slight catarrhal pyelitis. 

Symptoms. — The small deposits give no symptoms, and even quite 
large calculi may be found at autopsy where no indication of their pres- 
ence had existed during life, as in the case above mentioned. At other 
times symptoms are produced which resemble those of renal calculi in 
the adult. 

There may be tenderness with pressure, pain localized over the affected 
kidney, or radiating to the bladder, the perinseum, and even the opposite 
kidney, and there may be irritation and retraction of the testicle. The 
urine may show, especially after exercise, a trace of blood ; there may be 
the added symptoms of pyelitis, with some fever, localized tenderness, 
and the appearance in the urine of pus and epithelial cells from the pelvis 
of the kidney. 

Renal colic is produced when a stone of any considerable size passes 
from the kidney to the bladder. It is characterized by symptoms similar 
to those seen in the adult. There are sudden attacks of severe sickening 
pain in the loins, shooting down the thigh or to the testicle. There may 
be vomiting and even collapse. The urine is passed frequently, in small 
quantities, and contains blood. The symptoms quickly subside when the 
stone reaches the bladder. The calculus may sometimes become impacted 
in the ureter and give rise to hydronephrosis or pyonephrosis, which soon 
becomes pyelo-nephritis. 

Treatment. — The treatment of renal calculi in children is to be con- 
ducted upon the same general principles as in adults. Small calculi may 
be suspected, but a positive diagnosis is impossible except by the passage 
of gravel in the urine. When these conditions exist the diet should be 
largely fluid, and alkaline waters freely given. When the calculi are large 
enough to give positive symptoms, which continue to increase in severity, 
a surgical operation should be considered, and it should be urged in propor- 



PERINEPHRITIS. 63] 

tion to the severity of the symptoms aiid the clearness of the diagn 
If calculous pyelitis exists, it is certain sooner or later to lead to serious 
nephritis, and it is only a question of time when the kidney will be dis- 
abled. The same is true of hydronephrosis from the impart ion of a cal- 
culus in the ureter. Aldibert has collected four cases of nephrectomy in 
children for renal calculi in which the kidney was healthy, with three 
recoveries and one death from shock. In nine cases of operation for cal- 
culous pyonephrosis, there were six recoveries and three deaths. Tin- is 
certainly an encouraging showing, and should lead one to consider opera- 
tion seriously in many cases for which formerly nothing was done. The 
earlier the operation the greater the chances of Buccess, because of the 
better condition of the other kidney. Although the continued use of 
water and the so-called solvents may relieve some of the symptoms, it 
is very questionable whether they do more. 

TRAUMATIC HYDRONEPHROSIS. 

In addition to the hydronephrosis which results from congenital mal- 
formations and from the impaction of calculi, a form is occasionally seen 
following severe injury to the kidney. The pathology of hydronephrosis 
in these cases is not well understood. After the early symptoms 
traumatism have subsided, there develops in from two weeks to two 
months a tumour in the region of the kidney, which may reach a consid- 
erable size and present all the ordinary characteristics of hydronephr 
arising from other causes. This tumour may disappear spontaneously, 
or it may increase in size and demand surgical intervention for its cure. 
In seventeen cases which Aldibert has collected there was onlj one of 
spontaneous recovery ; aspiration was done in seven cases, with sii cures 
and one death; incision with or without nephrectomy was practised in 
nine cases, with seven recoveries and two deaths. 

PERINEPHRITIS. 

This consists in an inflammation in the cellular tissue mutouh.1i: 
kidney, which may terminate in resolution or in suppuration, [t 
of very uncommon occurrence, and is of importance chieflj from th< 
quency with which it is confounded with disease of the hip or Bpine. 
Perinephritis maybe secondary to suppurative processes in the 
itself, whether from calculi or tubercular deposits, or it maj be 
In children the latter is the eon.,. ion for.,.. Primary perinephral 
attributed to traumatism, cold, or exposure, or it maj 
assignable cause. It usually runs an acute or subacute i 
it may be chronic. 

For the clinical picture of this disease I am chiefly indebted 
paper by Gibney, who published in L880 a report of twenty-eight 



032 DISEASES OF THE UROGENITAL SYSTEM. 

primary perinephritis in children. I was at that time an interne in the 
Hospital for the Kuptured and Crippled, New York, where these cases 
were under observation, and had an opportunity to see many of those 
reported in Dr. Gibney's paper.* 

The ages of these patients were between one and a half and fifteen 
years, the majority being between three and six years. The two sides 
and the two sexes were about equally affected. About one third of the 
cases were clearly traceable to traumatism ; in the others no adequate 
exciting cause could be discovered. The majority of the cases were re- 
ferred to the hospital with the diagnosis of hip- joint disease or caries of 
the spine. Eesolution followed in twelve of these cases, and sixteen ter- 
minated in suppuration. 

When abscess forms, it usually burrows between the lumbar muscles 
and comes to the surface posteriorly near the middle of the ileo-costal 
space ; it may burrow forward between the abdominal muscles and point 
just above Poupart's ligament ; very rarely it may follow the psoas muscle 
and appear at the upper and inner aspect of the thigh, like an ordinary 
psoas abscess ; or it may open into the peritoneal cavity. 

Symptoms. — The onset of acute perinephritis may be quite abrupt, 
with chill, fever, and localized pain ; or it may be gradual, with stiffness of 
the spine, lameness referred to the hip, and deformity due to contraction 
of the flexors of the thigh. The pain is usually felt in the loin, but may 
be referred to the groiu, to the inner side of the thigh, or to the knee. 
It is often severe, and increased by using the limb. It is in most cases 
accompanied by localized tenderness in the neighbourhood of the kidney. 
There is lameness upon the affected side which may come on gradually, 
being sometimes referred to the hip and sometimes to the spine. These 
symptoms often develop slowly in the course of two or three weeks. They 
are usually accompanied by a slight elevation of temperature. In the 
most acute cases the temperature is high (102° to 104° F.), and prostration 
severe. 

As the disease progresses fever is a constant symptom, the temperature 
usually varying between 101° and 103° F. There is in most cases increas- 
ing deformity, and finally the patient may be unable to walk at all. On 
examination at the height of the disease there is found in a typical case 
a deviation of the spine with the concavity toward the affected side ; the 
thigh may be held flexed to a right angle ; passive extension is resisted 
and causes pain, although all the other movements at the hip joint are 
normal. In the lumbar region there is tenderness, and there may be an 
area of infiltration filling the ileo-costal space. At first this is only ap- 
preciable by percussion, but later a distinct tumour is present. In 



* Chicago Medical Journal and Examiner, 1880. where will be found a very full 
bibliography. 



PERINEPHRITIS. (533 

addition to the tumour in the usual region, there is sometimes one at 
the upper and inner aspect of the thigh, owing to a burrowing of pus, and 
the sacs may communicate. 

Lameness, pain, deformity, and fever sometimes exist for two or three 
weeks before any tumour can be made out. The constitutional symp- 
toms are often severe, and symptoms of the typhoid condition may even 
be present. The bowels are usually constipated. The size of the abs 
is sometimes very great. In one case I have seen it extend from the spine 
to the median line in front, and from the crest of the ileum nearly to the 
free border of the ribs. The amount of pus varies from a few ounces to 
two or three pints. Urinary symptoms are sometimes wanting ; at other 
times there is increased frequency of micturition, accompanied by pain 
from an irritation referred to the bladder. The urine may contain pus 
from a complicating pyelitis. In only one of Gibney's cases was this 
present. It developed in the fourth week, and the case recovered. 

The duration of the disease in the acute cases varies from tin 
eight weeks; in the subacute it may be five or six months. When sup- 
puration occurs the symptoms subside quite rapidly after the pus has been 
evacuated, and recovery is complete. Where resolution takes place, there 
is a gradual subsidence of the symptoms, and often some stiffness of the 
thigh, with slight lameness for several months. In the series 
above referred to, 65 per cent recovered completely in three months. 

Diagnosis. — In many cases a diagnosis of hip-joint disease is made, and 
they are reported as "hip-joint disease cured without deformity," etc. 
The points of differential diagnosis are quite distinct, and if a careful ex- 
amination is made there is no excuse for confounding the two conditions. 
Hip-joint disease develops more insidiously, is very much more chronic, 
and rarely produces so great deformity in a year as is often Been in peri- 
nephritis in two or three weeks; abscess is infrequent during the first 
year of the disease; on examination, there is found limitation «>f all the 
movements of the joint, and not of extension alone; atrophy of the thigh 
and joint tenderness are present. In perinephritis, on the other hand, 
have a tolerably acute onset, sometimes with chill, fever, marked I 
and deformity, developing in two or three weeks; abscess often forma in 
a month, and complete and permanent recovery nsnally follow* 
few months at most; the deformity is due Bolely to flexion of the tfa 
all other movements at the hip may be free, and joinl tenden 
Psoas abscess from Pott's disease may cause deformity, tumour, and I 
ness similar to that seen in perinephritis, bu1 on examination thei 
found the angular prominence and other signs of disease oi the lumbar 

vertebras. 

Prognosis.— Primary perinephritis in children almosl invariably termi- 
nates in complete recovery. Of the twenty-eighl I to, and 
eight subsequently observed by Gibney, all recovered perfectly. The 

49 



634: DISEASES OF THE URO-GENITAL SYSTEM. 

condition liable to prove fatal is rupture of the abscess into the peritoneal 
cavity. 

Treatment. — The patient should be put to bed and kept as quiet as 
possible throughout the attack. In the early stage, a blister, hot fomen- 
tations, or an icebag, should be applied over the affected side; heat is 
generally to be preferred. When suppuration is inevitable and pain severe, 
a poultice may be used. Abscesses should be opened early, to prevent 
burrowing, and danger of a possible rupture into the peritoneal cavity. 

GENERAL (EDEMA NOT DEPENDENT ON RENAL DISEASE. 

This is of not very infrequent occurrence in infants and young chil- 
dren. In the Babies' Hospital, during the last seven years, over fifty cases 
have been observed. Nearly all were in infants under six months of age, 
and the majority have been under three months. .This general dropsy 
was invariably associated with extreme malnutrition and anaemia. It 
comes on gradually in the course of four or five days, often the first thing 
noticed being that a wasting child has unexpectedly increased half a 
pound or a pound in weight. On closer inspection there will be found 
oedema of the feet, ankles, thighs, face, hands, and sometimes of the 
abdominal walls, and the back. This may be quite marked, so that it 
may be almost impossible to open the eyes, and the extremities may be 
nearly double their normal size. I have occasionally seen dropsy in the 
serous cavities. No explanation of this oedema is found in the urine. It 
is not albuminous; it is frequently very scanty, but is sometimes appar- 
ently normal in amount. Opportunities for the examination of the kid- 
neys have been afforded in several instances, and these organs have been 
in all cases normal, even upon microscopical examination. 

The cause of this oedema was ascribed by Tarnier, who had observed 
it in connection with premature infants fed by gavage, to the giving of 
too much fluid food. He states that it disappeared when the amount of 
food was reduced. This has not been my experience. Many children 
who were fed by gavage showed no signs of it, and others who took a 
comparatively small quantity of food became oedematous. The best expla- 
nation seems to me to be that it depends upon a condition of hydremia, 
associated with feeble resistance in the walls of the small blood-vessels, 
through which a transudation of serum readily takes place-. The degree 
of anaemia noted in these patients is sometimes extreme. 

The prognosis in this condition is extremely bad, as it rarely occurs 
except in hopeless cases of marasmus. This is not, however, invariably 
the case. The dropsy may disappear to return again, or it may disappear 
permanently and the case go on to recovery. 

If the urine is scanty, such diuretics as the citrate of potash and the 
sweet spirits of nitre often cause a diminution and sometimes even a 
disappearance of the dropsy in a short time. The best of all remedies, 



MALFORMATIONS OF THE GENITAL ORGANS. 635 

however, is digitalis. To an infant of two months, v\ -^ of the fluid 
extract may be given every two hours for two or three days ; and for a 
short period somewhat larger doses may be employed. 



CHAPTER III. 

DISEASES OF THE GENITAL ORGANS. 

MALFORMATIONS. 

Adherent Prepuce. — This condition is sometimes called false phimosis. 
It is so constantly present that it can hardly be regarded as a malforma- 
tion. It is, however, a condition needing attention in every male infant. 
The prepuce should be forcibly retracted so as to expose the glans com- 
pletely. The smegma should then be washed away, the glans covered 
with a drop of oil, and the skin drawn forward. This should be repeated 
daily until there is no disposition to a recurrence of the adhesions. 

Phimosis. — This is such a narrowing of the prepuce that it can not be 
retracted over the glans. The degree of phimosis varies greatly. In very 
rare cases there is no preputial opening. In other cases the orifice is so 
small that no part of the glans can be exposed, and there is obstruction to 
the outflow of urine ; but usually a small part of the glans can be seen. 
Phimosis may be complicated by an elongated prepuce (hypertrophic phi- 
mosis), and the elongation may exist without any narrowing of the orifice, 
although this is usually present to some degree. 

The presence of phimosis makes cleanliness impossible in many cases, 
and want of cleanliness leads to infection and to balanitis. This is quite 
frequent even in infants. It may be complicated by urethritis, and even 
by cystitis. Another consequence of the straining induced by phimosis 
is hernia, which may be either inguinal or umbilical. To cure the 
hernia is often impossible, unless the phimosis is relieved. Straining 
also leads to prolapsus ani, and, from pressure on the spermatic vessels, to 
hydrocele. More important even than these mechanical results of phimo- 
sis are the reflex conditions resulting from the irritation. Such symptoms 
may come from preputial adhesions as well as from phimosis. The 
hyperaesthetic condition and the resulting pruritus cause frequent pria- 
pism, and are among the most common causes of masturbation. It may 
produce other nervous symptoms, such as insomnia, night terrors, etc. 
Phimosis often causes frequent micturition, dysuria, and, in fact, most of 
the symptoms of stone in the bladder. It sometimes leads to vesical 
spasm and retention of urine, but more frequently to nocturnal inconti- 
nence. 



(536 DISEASES OP THE URO-GENITAL SYSTEM. 

The list of reflex phenomena which have been attributed to phimosis 
is a long one, and includes most of the functional nervous diseases of 
childhood. There is abundant evidence that phimosis may be a cause, 
although a rare one, of chorea, convulsions, epilepsy, hysterical mani- 
festations, pseudo-paralysis, spasm of the muscles about the hip causing 
symptoms resembling the early stage of hip-joint disease, strabismus, 
amaurosis, diarrhoea, and many other nervous conditions. There is, how- 
ever, no evidence that cases of spastic diplegia or paraplegia are ever 
caused by phimosis or improved by circumcision. There has been in the 
past a disposition on the part of some writers to attribute nearly all the 
nervous disturbances of boyhood to phimosis, and an exaggerated im- 
portance has certainly been attached to this condition. Still, in a delicate, 
anaemic child with unstable nervous centres, phimosis is capable of giving 
rise to nervous symptoms of a most serious and alarming character. It 
is an important etiological factor in many neuroses, and one which 
should not be overlooked. On the other hand, a very marked degree of 
phimosis often exists in robust children without producing any symp- 
toms whatever. 

Treatment. — Every case of phimosis should receive attention in in- 
fancy. Often very little treatment is needed ; but trouble is likely to 
come sooner or later if it is neglected. When there is a very long prepuce 
with phimosis, the operation of circumcision should invariably be done, 
even when the degree of phimosis is slight. Many cases of phimosis in 
which the prepuce is not long can be relieved by stretching. If no part 
of the glans can be exposed, the simplest plan is to slit up the dorsum 
of the prepuce with "a pair of scissors and forcibly break up the adhesions. 
The corners of the flaps thus made can then be snipped off and one stitch 
inserted on either side. This is very easily done, and gives most ex- 
cellent results. In the case of obscure nervous symptoms in older boys, 
the condition of the prepuce should be examined and the same rules of 
treatment applied. In all cases of hernia, hydrocele, or prolapsus ani, 
when phimosis is present it should be relieved as the first step in the 
treatment. 

Hypospadias. — In this condition the urethra is not continued to the 
tip of the penis, but opens on the inferior surface some distance back, 
being represented in front of this only by a shallow furrow. In more 
severe cases there is a deep fissure which divides the scrotum, and some- 
times even the perinaeum. Into this fissure the urethra opens. This is a 
condition likely to be mistaken for that of hermaphrodism, especially as 
the testicles are frequently in the abdominal cavity. It may be impossible 
to decide the sex of the child until puberty. Surgical operations for the 
relief of these deformities are not very successful. 

Epispadias. — This is a condition in which the urethra opens on the 
dorsal surface of the penis. It is much less frequent than hypospadias. 



MALFORMATIONS OP THE GENITAL ORGANS. 637 

There may be simply a division of the glans, or the fissure may extend the 
whole length of the organ and be complicated by — 

Exstrophy of the Bladder. — This deformity is met with in all degrees of 
severity. In the complete form there is a median fissure from the umbili- 
cus to the tip of the penis. It includes the anterior abdominal wall, the 
pelvic bones, and the urethra. The bones are entirely separated at the 
symphysis, or connected behind the bladder by a fibrous band. The hypo- 
gastric region is occupied by a red, mucous surface, slightly corrugated, 
which is all .there is of the bladder. This is generally surrounded by a 
narrow rim of integument. In the lower lateral portions of the red 
mucous membrane two slightly rounded elevations are seen, from which 
urine oozes. These are the openings of the ureters. The penis is short, 
and presents a shallow furrow on its dorsal surface. With this deformity, 
also, the testes are often in the abdominal cavity. 

An analogous deformity is sometimes seen in girls. There is a division 
of the clitoris and the labia minora and majora. The fissure may be so 
deep as to reach nearly to the anus. The vagina is usually absent. The 
rectum may open into the prolapsed. bladder. 

All these deformities are compatible with long life. In most of them 
the individual is incapable of procreation. In exstrophy of the bladder, 
whether complete or partial, patients are a nuisance to themselves and to 
all about them. It is almost impossible to prevent the clothing from 
being soaked with urine, which gives everything connected with the pa- 
tient a strong ammoniacal odour. The skin is often excoriated. Opera- 
tion for the relief of these cases should, I think, always be undertaken. 
Brilliant results have been obtained even in some of the most severe cases. 

Undescended Testicle — Cryptorchidism. — In foetal life the testes are 
situated in the abdominal cavity below the kidneys. They usually descend 
into the scrotum during the ninth month, but in children born at full 
term the testicle may be in the inguinal canal, or even in the abdomen. 
The former condition is quite a frequent one, being present, according to 
good authorities, in fully ten per cent of all children. In the great 
majority of these the descent takes place without difficulty during the 
first weeks of life, and causes no symptoms. In others the condition per- 
sists. The testicle may be found in the abdominal cavity or at any point 
in the canal. If the latter, it may be felt as a small, hard tumour, slightly 
painful upon pressure. Even in some of these cases a natural descent 
takes place about puberty, usually without symptoms. The testicle occa- 
sionally makes for itself a false passage, and is found in the perinaBtim. 
When in the inguinal canal, descent of the testicle into the scrotum 
may sometimes be facilitated by manipulation. In other situations it 
had best be left alone, unless it gives rise to much pain or tenderness, 
as may happen when a false passage has been made. It should then bo 
removed. 



638 . DISEASES OP THE URO-GENITAL SYSTEM. 

With the exceptions already mentioned, deformities of the female geni- 
tals belong rather to gynaecology than to paediatrics, since they are chiefly 
of the internal organs, and do not usually give symptoms before puberty. 

DISEASES OF THE MALE GENITALS. 

Balanitis. — Balanitis, or inflammation of the prepuce, is one of the 
results of phimosis. It may follow decomposition of the smegma, infec- 
tion of the mucous membrane, injury, or masturbation. The parts are 
swollen, cedematous, red, painful, and sometimes bathed in pus. Eetrac- 
tion of the prepuce is impossible. Under proper treatment the inflamma- 
tion usually subsides in two or three days, but there may be some dis- 
charge for a considerable time. Abscess may follow, and even gangrene 
of the prepuce. The most severe cases are likely to be complicated with 
anterior urethritis. 

The object of treatment is to remove the irritating and infectious 
material lodged beneath the foreskin. This may be quite difficult. It is 
best accomplished by syringing with a l-to-5,000 bichloride solution. 
This should be repeated several times a day, the prepuce being held in 
contact with the syringe, so that it is distended by the injection. Where 
it is impossible to do this, an antiseptic lotion may be used and ice applied 
until the oedema has subsided. It is sometimes necessary to slit up the 
prepuce before the parts can be thoroughly cleansed, and in severe cases 
this is often the quickest method of cure. Circumcision should not be 
done during an attack. 

Urethritis. — This, like the same disease in females, may be simple or 
specific. Both forms are less frequent in little boys than in the other sex. 
In simple urethritis the inflammation usually affects only the anterior part 
of the canal, the fossa navicularis. There is a slight discharge of pus, and 
sometimes pain on micturition. The most frequent cause is want of 
cleanliness. 

Gonorrhoeal inflammation is more common. This occurs even in boys 
as young as eighteen months, but most of the cases are in those over 
seven years old. The usual cause is direct contagion. The symptoms are 
more severe than in the simple form, and resemble the same disease in 
the adult, with the exception that constitutional symptoms are usually ab- 
sent. A microscopical examination of the discharge (page 642) is the only 
positive means of diagnosis between the two varieties. In these cases it 
reveals the gonococcus in great numbers. Conjunctivitis and arthritis 
are seen as complications, just as in the female. Orchitis is very rare, 
but balanitis and bubo are not infrequent. Poynter has reported a case 
in a boy of three years, who, when five years old, required treatment for a 
urethral stricture. He was infected by a nurse. 

The first thing in the treatment is always to keep the parts covered, 
otherwise the infection is almost certain to be carried by the hands to 



HYDROCELE. 639 

other raucous membranes, usually the conjunctiva. In other respects the 
treatment is the same as in the adult. 

Hydrocele. — Hydrocele consists in an accumulation of serum in some 
part of the serous pouch brought down by the testicle in its descent. In 
infants it is usually due to the imperfect closure of this pouch at some 
point, where a fluid accumulation occurs. Four varieties of hydrocele are 
met with in young children : 

1. Congenital hydrocele. — In this the condition is a congenital one, 
although the tumour is not necessarily present at birth. The tunica vagi- 
nalis communicates with the general peritoneal cavity. There is present 
an elongated tumour, extending from the bottom of the scrotum through- 
out the whole length of the cord. The tumour is reducible, sometimes 
spontaneously by position, sometimes, when the opening is smaller, only 
by pressure. It reduces slowly, without gurgling, never going back en 
masse like a hernia. The tumour is translucent, and is flat on percus- 
sion. The testicle is above and posterior, and usually indistinctly felt. 
Congenital hydrocele may be complicated by hernia. 

2. Hydrocele of the tunica vaginalis with the canal closed. — In this 
form the accumulation of fluid is in the scrotum, communication with the 
peritoneal cavity having been entirely cut off by the complete obliteration 
of this pouch in the canal in the normal way. This is one of the most 
frequent forms. It gives rise to an oval or pear-shaped tumour, quite 
tense and firm, usually about two inches in length. The cord is distinctly 
felt above it, the testicle is behind and somewhat above it, and not always 
felt very distinctly. This variety gives translucency and the usual elastic 
feeling of a hydrocele. 

3. Hydrocele of the cord. — This is one of the rare forms. The serous 
pouch which accompanies the spermatic cord is open above, and com- 
municates with the peritoneal cavity; but below it is closed. The scrotum 
is normal, and the testicle is in its usual position. The tumour is small, 
elongated, and reducible, and entirely above the scrotum. Usually it stops 
at some point in the inguinal canal. This hydrocele also may be compli- 
cated by hernia. The diagnostic points are the same as in the form first 
mentioned. 

4. Encysted hydrocele of the cord. — The peritoneal pouch of the cord 
in this variety is closed for some distance above, and again below, but 
somewhere in its course it is open, and here the fluid accumulates in 
the form of a cyst. When small it resembles an undescended testicle; 
but on examination this organ is found below and in its normal posi- 
tion. When in the canal, it is often mistaken for a lymph gland, some- 
times for a small hernia. The tumour is usually about the size of an 
almond. It is elastic and irreducible, and gives translucency like the 
other varieties. In cases of doubt it may be punctured by a hypodermic 
needle. 



640 DISEASES OF THE URO-GENITAL SYSTEM. 

Treatment of Hydrocele. — In the congenital form the first point is to 
cause obliteration of the canal, so as to shut off the hydrocele sac from the 
general peritoneal cavity. This is usually done by the use of a truss, and, 
if applied early, it may be accomplished in the course of a few months. 
It is subsequently managed like an ordinary hydrocele of the tunica 
vaginalis. In infants and young children it is rare that active operative 
measures are called for in any variety of hydrocele, as these tend, in a 
great majority of cases at least, to disappear spontaneously in the course 
of a few months. Absorption is often facilitated by the application of 
collodion. In many cases the internal administration of iodide of po- 
tassium, twelve grains a day, causes a rapid disappearance of the effusion. 
Iodine may be applied locally over a hydrocele of the cord, but should 
not be applied to the scrotum. In some cases which do not disappear 
promptly, simple puncture with the needle, allowing the fluid to drain off 
into the cellular tissue of the scrotum from which it is absorbed, is an 
excellent means of treatment. Others are cured by a single aspiration 
with hypodermic syringe. I have treated in the neighbourhood of one 
hundred of these hydroceles in infants and young children, and have 
never yet seen one in which it was necessary to resort to the injection of 
irritants like iodine or carbolic acid. 



DISEASES OF THE FEMALE GENITALS. 

VULVOVAGINITIS. 

This is a catarrhal inflammation, usually affecting the mucous mem- 
brane of the vulva, vagina, urethra, and often that of the cervix uteri. 
It may be simple or specific (gonorrhceal). Neither form is very rare. 

Simple Vulvo-vaginal Catarrh. — This may be seen at any age, even in 
infancy. It is, however, most frequent after the second year. It more 
often occurs in girls who are anaemic, or suffering from malnutrition, 
than in those whose general health is good, being especially common in 
those who live in unhygienic surroundings or where personal cleanliness 
is neglected. It may follow any of the infectious diseases, particularly 
measles. There seems to be little doubt that even this form may be 
spread by contagion. It is common in children in institutions, where 
small epidemics are sometimes seen. It may be communicated by direct 
contact, or by handling the parts, or through clothing, diapers, sponges, 
towels, etc. The disease may be traumatic, as from attempted rape,* or 
the introduction of foreign bodies. It may be secondary to the presence 



* See " Twenty-one Cases of Rape in Young Girls," by Walker, Archives of Paedia- 
trics, vol. iii, 1886, where the medico-legal points with reference to this condition are 
fully discussed. 



VULVOVAGINITIS. 641 

of pinworms, or to scabies, and it is sometimes the cause, sometimes the 
result, of masturbation. 

Symptoms. — The • disease generally begins as a subacute catarrhal in- 
flammation, the discharge being the first thing noticed. In the milder 
cases this is thin and yellowish- white, with some pain on locomotion, itch- 
ing, and burning on micturition. In the more severe form it is abundant 
and of a yellowish-green colour, causing the labia to adhere, and the secre- 
tion, drying, forms crusts. The odour is sometimes extremely fetid, and 
the skin of the thighs may be excoriated. The local examination shows 
the mucous membrane to be red, swollen, cedematous, and bathed in pus. 
All the visible parts — urethra, hymen, vagina, etc. — are involved. By 
using an ordinary urethral speculum in the vagina, pus may be seen in 
most of the severe cases to come from the cervix uteri (Koplik). There 
are no constitutional symptoms. There may be swelling, and even sup- 
puration, of the inguinal glands. The disease has no definite course, but 
usually with proper treatment lasts from one to three weeks, when there 
may be complete recovery, or there may persist for a long time a leucor- 
rhoeal discharge. In children who are in poor general condition, and 
where proper means of treatment are neglected, vulvo-vaginitis may last 
for months. 

Gonorrheal Vulvo-vaginitis (Uro-genital Blennorrhea). — Recent studies 
of the micro-organisms in the discharge have shown cases of true gonor- 
rhoea in young girls to be very much more numerous than was formerly 
suspected.* While indirect infection is no doubt possible, and in certain 
cases proved, nearly all writers agree that this is very exceptional, and 
that the most common origin of the disease is direct contact, either inten- 
tional or accidental, with another case of gonorrhoea, sometimes sexual 
and sometimes by the hands. In this way the disease may be conveyed 
from one child to another, or from adults to children, very often from 
parents who occupy the same bed with the child. Pott states that, in 90 
per cent of his forty-four cases, the mothers were found to be suffering 
from leucorrhoea. The mode of contagion may be difficult to trace, but 
this fact should cast no doubt upon the diagnosis in the case. The dis- 
ease occurs in girls of all ages, but chiefly between three and eight years. 
Epstein has reported cases in the newly-born. The incubation in three 
cases in which it could be definitely traced, was exactly three days (Cahen- 
Brach). 

Symptoms. — The disease is believed to begin usually in the urethra, 
although this is in most cases difficult to establish, as then 1 are generally 
found on the first examination evidences of inflammation of all the mucous 



* For an excellent riaumi ot this subject, with references to recent literature, sec 
Koplik, Journal of Cutaneous and Genito-Urinary Diseases, June, L803; also Beiman, 

New York Medical Record, June 22, 1895. 
50 



642 DISEASES OF THE URO-GENITAL SYSTEM. 

membranes of this region. There is a copious secretion of thick, yellow- 
pus. There may be erosions of the vaginal mucous membrane, so that 
the parts bleed readily. Crusts form on the labia. When a view of the 
cervix can be obtained by means of a small speculum, this is almost inva- 
riably seen to be involved. For the first day or two, in the most severe 
cases, there may be slight fever and general indisposition, but more fre- 
quently — and this is one of the most striking points of difference from 
the disease as seen in adults — constitutional symptoms are wanting alto- 
gether. Micturition is painful, and sometimes frequent, there are also 
excoriations of the skin, and difficulty in walking, all these symptoms 
being usually more severe than in simple catarrh. The duration of these 
cases is indefinite, being from one to six months. Under the most favour- 
able conditions it is several weeks, largely owing to the great difficulties 
in the way of a thorough application of local treatment. It is always 
more obstinate than is a simple catarrh. 

A positive diagnosis between the simple and gonorrhoeal catarrh can be 
made with certainty only by a microscopical examination of the discharge. 
The pus for examination should be taken from as high a point in the 
tract as possible, preferably the orifice of the urethra, in order to avoid 
contamination. In a simple catarrh the discharge is made up of epithelial 
and pus cells, with quite a variety of bacterial forms — bacilli, cocci, and 
diplococci. These bacteria are found in the epithelial cells and in the 
pus cells, but they are generally associated, and the diplococci are few in 
number. In cases of gonorrhoeal inflammation there are found in the 
pus cells large masses of diplococci, these being usually the only bacteria 
present. It should then be emphasized that the mere presence of a few 
diplococci, even though found in the pus cells, is not enough to establish 
the diagnosis of gonorrhoea, since there are varieties of diplococci found 
in the simple catarrh, and even in the normal vaginal secretion, which 
morphologically closely resemble the gonococcus of Neisser. It is the 
presence of these in large masses in the pus cells which is the character- 
istic feature (Koplik). According to the very careful observations of 
Heiman, the two varieties of diplococci may be positively differentiated 
by staining by Gram's method. The gonococcus is decolourized, while 
the other form is not. 

Nearly all the complications of gonorrhoea which are seen in the adult 
have been observed in young children, but the majority of them are rare. 
The most frequent one is conjunctivitis, infection being carried by the 
hands from the vaginal discharge to the eyes. Gonorrhoeal arthritis is not 
common, but may affect the knee, ankle, wrist, or elbow. The symptoms 
of arthritis resemble those of ordinary rheumatism. Cystitis is extremely 
rare. Bubo is occasionally seen, and may be simple or suppurative. As 
already stated, the disease in many, probably in nearly all the severe 
cases, affects the lining of the uterus. Infection may extend from the 



HERPES OP THE VULVA. 643 

uterus to the tubes and cause pyosalpinx, or even peritonitis. Sanger 
reports a case of pyosalpinx from gonorrhoeal infection in a little girl of 
three years, and Huber a fatal case of peritonitis of similar origin in one 
of seven. I have myself seen one of severe pelvic peritonitis in a girl of 
seven. In all these cases the diagnosis of the gonorrhceal origin of the 
disease must rest upon the presence of gonococci in the vaginal discharge. 

Treatment of Vulvo-Vaginitis, — The first thing is proper isolation, and 
care to prevent the spread of infection by means of clothing, linen, etc. 
In institutions, and in families where there are many children, the great- 
est care is necessary even in catarrhal cases. 

Simple vaginal catarrh requires cleanliness, which is best secured by 
irrigating twice daily with a warm saturated solution of boric acid, or 1 to 
10,000 bichloride. A pad of sterilized absorbent cotton, the meshes of 
which are filled with boric acid and starch, or iodoform, may be placed 
between the labia in the most severe cases, the patients being kept in bed. 
The skin should be protected by ointments. In obstinate cases, irrigation 
with astringent solutions, such as sulphate of zinc or tannic acid, may be 
used. More radical means are rarely required. Attention to the general 
condition of the patient must not be overlooked, and the health should 
be built up by iron, cod-liver oil, and other tonics. Every young child 
should wear a napkin, to prevent carrying the disease to the eyes by the 
hands. 

In the gonorrhceal cases nothing is so efficient as the irrigation with 
the solutions above referred to. They should, however, be employed more 
frequently ; in the early stage, where the secretion is abundant, as often as 
three or four times a day. In cases passing to the chronic stage, a solution 
of nitrate of silver, ten grains to the ounce, may be applied to the vagina 
through a speculum. This should be repeated every second or third day. 
In all circumstances these cases are tedious, and require the closest atten- 
tion to detail to insure the best results. Kelapses are not uncommon in 
cases which had apparently recovered. 

HERPES OF TnE VULVA. 

This may occur on the cutaneous surface only, or there may be a 
herpetic condition of the mucous membrane. The skin of the perineum 
may be involved, and the disease may extend quite to the anus. On the 
skin, the eruption runs the ordinary course of herpes elsewhere. Vesicles 
form and rupture or dry, forming crusts or leaving small ulcers, which 
heal in a week or ten days if the parts are simply protected. On the 
mucous membrane the vesicles arc succeeded by small ulcers, which may 
coalesce and form larger ones, the appearance resembling the same con- 
dition in the mouth. The symptoms are itching, burning pain, and a 
slight discharge. The herpetic ulcer may be confounded with a mucous 
patch. These cases usually recover promptly if dusted with some absorb- 



644 DISEASES OP THE URO-GENITAL SYSTEM. 

ent powder like boric acid and oxide of zinc, or talcum. In addition, 
cleanliness should be secured. It is important that this condition should 
be attended to, as it is sometimes followed by more serious disease. 

GANGRENOUS VULVITIS (NOMA). 

This is the same process as that seen in the mouth and known as 
cancrum oris. It usually follows one of the infectious diseases, most fre- 
quently measles, occurring in patients whose general vitality has been 
greatly reduced. The condition may succeed a simple catarrh or a her- 
petic vaginitis. There is first noticed a tense, brawny induration, the 
skin being shiny and swollen over a circumscribed area. In the centre of 
this there soon appears, usually upon one of the labia majora, a dark, cir- 
cumscribed spot. Day by day the gangrenous area advances, preceded by 
the induration. It may involve the whole labium, extending even to the 
mons veneris and the perinseum. These cases are generally fatal. If re- 
covery takes place, it is with considerable deformity of the parts in conse- 
quence of the extensive sloughing and cicatrization. As sequela?, there 
may be fistulae, stenosis, or atresia of the vagina. The prognosis is very 
bad. The only radical treatment is early excision of the gangrenous part, 
and the application of the actual cautery or nitric acid. 



CHAPTER IV. 

ENURESIS. 
Synonyms : Incontinence of urine ; bed-wetting. 

Enttkesis may be due to some malformation of the genital tract, such 
as an abnormal opening of the bladder into the vagina, to extroversion of 
the bladder, or to the persistence of the urachus ; in the latter case the 
urine may be discharged from the umbilicus. It also occurs in organic 
diseases of the central nervous system, such as idiocy, cerebral palsy, 
acute meningitis, tumours of the brain, certain forms of myelitis, and in 
injuries of the cord. In many of these conditions there is associated in- 
continence of fasces. Both of the groups of cases mentioned are quite 
distinct from the ordinary form of incontinence of urine which is seen in 
childhood. The latter is to be regarded as a neurosis, and is the only 
variety which will be considered here. 

In early infancy, evacuation of the bladder is purely a reflex act. An 
impulse is sent from the nerves of the bladder to the spinal centre, and a 
reflex impulse from this centre produces simultaneously a contraction of 
the detrusor urinae and a suspension of the contraction of the vesical 



ENURESIS. 645 

sphincter. It is often possible to teach infants to control the evacuation 
of the bladder before the end of the first year ; usually, however, control 
is not acquired even during waking hours until some time during the sec- 
ond year, and in some healthy infants not before the end of the second 
year. The time depends very much upon the training. If a child during 
its third year can not control the evacuation of the bladder during its 
waking hours, incontinence may be said to exist. 

Etiology. — Incontinence of urine may be due to a continuance of the 
infantile condition, to anything which increases the irritability of the 
spinal centre, or which interferes with the cerebral control over this 
centre, or to anything which increases the irritability of the peripheral 
fibres of the vesical nerves or of those in the neighbourhood, in conse- 
quence of which too many or too strong impulses are sent to the spinal 
centre. The causes of incontinence thus may be in the central nervous 
system, in the urine, in the bladder, or in any of the adjacent organs. 

The causes relating to the central nervous system are in the main 
those of the other neuroses of childhood ; these are anaemia, malnutrition, 
an inherited nervous constitution, or a condition of extreme nervousness 
or neurasthenia, the result of the child's surroundings. In such cases 
incontinence is often associated with chorea, epilepsy, hysteria, headaches, 
neuralgia, and other nervous symptoms. In these conditions there may 
be not only an increased irritability of the nerve centres, but also of the 
peripheral nerves, accompanied by loss of tone of the vesical sphincter. 
A similar condition may exist with almost any form of acute illness, 
usually, however, being only temporary. 

The causes referable to the urine are chiefly a highly-acid urine, gen- 
erally associated with lithuria. In such cases the incontinence is very 
often due more to the constitutional than the local condition. 

In the bladder itself, cystitis and vesical calculus, although infrequent, 
should not be overlooked as possible causes. In a few cases, where incon- 
tinence has existed a long time, the bladder becomes so contracted that it 
will hold only an ounce or two of urine. This condition, although not 
the primary cause of enuresis, may be enough to continue it. 

Local irritation in the neighbouring organs may be due to adherent 
prepuce, balanitis, phimosis, or to a narrow meatus. All of these condi- 
tions are frequently associated with incontinence. Rectal irritation may 
be caused by pinworms, anal fissure, or rectal polypus ; and vaginal irrita- 
tion by vulvo-vaginitis or adherent clitoris, both, however, being extremely 
rare. Often we have incontinence as the result of a combination of sev- 
eral causes, no one of which alone would have been sufficient to produce 
it. Thus, in a healthy child phimosis may give rise to no symptoms, while 
in one who is anaemic or neurasthenic it may produce enough local irri- 
tation to cause incontinence. In many cases heredity seems to be a 
factor of some importance, parents often having suffered in their child- 



64:6 DISEASES OF THE URO-GENITAL SYSTEM. 

hood from the same disease ; quite frequently there are seen two and 
sometimes even three children in the same family affected. In many 
cases the condition seems to be mainly the result of habit, and in all cases 
habit is a potent factor in continuing the incontinence, sometimes after 
the original exciting cause has been removed. Frequently no adequate 
cause can be found. Both sexes are about equally liable to enuresis, and 
it may be seen in all ages up to puberty. 

Symptoms. — Enuresis may be nocturnal or diurnal, or both. Of 194 
cases, 73 were nocturnal, 9 diurnal, and 102 were both nocturnal and 
diurnal. Cases differ greatly in severity. Incontinence may be habitual, 
occurring every night, often several times during the night, and frequently 
during the day ; or it may be only occasional under the influence of some 
special exciting cause, where it continues a few days or weeks until the 
cause is removed. In a considerable number of cases, the condition lasts 
from infancy until the sixth or seventh year. It may even continue until 
puberty ; but it generally ceases at that period, unless its cause is mechan- 
ical, or depends upon some organic disease of the brain or cord. In ordi- 
nary enuresis there is never dribbling of the urine, but usually a contrac- 
tion of the walls of the bladder follows almost immediately upon the desire, 
before the patient can make his wants known or reach a convenient place 
for micturition. At night the same thing may occur without wakening 
the child, the contraction being of purely reflex origin. 

Prognosis. — The condition is usually hopeless when it depends upon 
organic disease of the brain and cord ; also in cases due to malformation, 
unless these are amenable to surgical treatment. In the ordinary cases 
seen, the prognosis depends upon the age of the child, the duration of the 
symptom, and the nature of the exciting cause. As a rule, it is better in 
children only four or five years old than in those of eight or nine, for the 
obvious reason that a case which has lasted to the latter age is usually an 
intractable one. If a cause can be discovered and if this is one that can 
be removed, the prognosis is much better than if no cause can be found. 
In the great majority of the cases a cure is possible, provided the patient 
can be held long enough to a regular plan of treatment. The treatment 
must in most cases be continued from three months to a year, and always 
for several months after the incontinence has ceased, on account of the 
strong tendency to relapses. 

Treatment. — The first indication is to remove the cause, where one can 
be found. If there are preputial adhesions, they should be broken up 
and irritating smegma removed. If phimosis is present, it should be re- 
lieved by stretching or circumcision. A narrow meatus should be cut to 
proper dimensions. If stone in the bladder is suspected, as it should be 
when the incontinence is worse by day and accompanied by straining and 
painful spasm of the bladder, the patient should be sounded for stone. 
Pinworms in the rectum should receive the appropriate treatment by 



ENURESIS. 647 

injections. A urine of high acidity, with deposits of uric acid, calls for 
alkalies and the free use of fluids, especially water. While the local con- 
ditions mentioned should always be attended to, the fact remains that few 
cases are cured simply by relieving them, except those due to vesical cal- 
culi. The explanation of this is that habit is so important a factor in 
keeping up incontinence where it has existed a long time. In most cases, 
therefore, we must depend upon general measures and drugs directed 
toward the relief of the symptom, either in conjunction with local treat- 
ment or alone. 

Care should be taken to secure for the child a simple, natural life, 
preferably in the country. There should be no overtaxing of the nervous 
system at home or in school. Every cause of unnatural excitement should 
be avoided. Early hours and plenty of sleep must be insisted upon. 
Certain articles of diet are to be avoided, and coffee, tea, and beer 
should be absolutely prohibited. Sweets and all highly seasoned food 
should be very sparingly allowed, or not at all. Although it is believed 
by many that a diet into which meat enters largely is injurious, from per- 
sonal experience I have not found the exclusion of meat to be of any ad- 
vantage ; nor is anything to be gained by limiting the amount of water 
which the child takes, except possibly in cases of nocturnal incontinence, 
where it is well to restrict the quantity taken late in the afternoon. When 
incontinence is associated with highly-acid urine, it is often aggravated 
by cutting down the fluids. The diet which succeeds best is a simple one 
composed of milk, vegetables, fruits, meats, and cereals. Punishments, 
whether corporal or otherwise, do no good, and are in most cases abso- 
lutely harmful. They should never be allowed. Eewards are much more 
effectual. The moral treatment of a case is important ; it is well to 
work upon a child's pride, and use every means to strengthen his will. 
Where the incontinence is solely or chiefly at night, the child should be 
taught to hold his water as long as possible during the day, in order to 
accustom the bladder to full distention. 

Measures which are directed toward the patient's general condition 
are quite as important as those employed for the control of the inconti- 
nence. Anaemia, chlorosis, malnutrition, indigestion, and constipation 
should each receive careful attention. Any local condition, such as ade- 
noid growths of the pharynx, which might serve to increase the general 
nervous irritability, should be removed. 

Of the drugs used for the purpose of affecting the incontinence, bella- 
donna stands at the head of the list; but it must be given in full doses, 
usually sufficient to produce the physiological effects, and continued for a 
long time, in most cases for many months. Either the fluid extract or 
the alkaloid, atropine, should be employed. My preference is for the 
latter, because of its more uniform strength. A convenient method of 
administration is to use a solution of atropine, one grain to two ounces of 



648 DISEASES OF THE URO-GENITAL SYSTEM. 

water, of which one drop (joVo of a grain) may be given for each year of 
the child's age. For nocturnal incontinence this dose should at first be 
given at 4 and 10 p. m. ; after a few days, at 4, 7, and 10 p. m. Usually 
this may be gradually increased until double the quantity is given. A 
child of five years would then be taking ten drops (y^-g- of a grain) at each 
of the hours mentioned. I have rarely found it advisable to go above 
these doses. As the larger doses are reached the increase should be more 
gradual. When the condition is under control, or when the full physio- 
logical effects of the drug are produced, the same dose should be con- 
tinued for some time and then reduced, the atropine being given for at 
least two months in gradually diminishing doses after the incontinence 
has ceased. This is very important if the cure is to be permanent, as 
there is so strong a tendency in these cases to relapse.* 

Strychnine may be added in cases not yielding to the atropine alone. 
It is particularly advantageous when there is diurnal as well as nocturnal 
incontinence, for under these conditions there is usually a lack of tone in 
the sphincter, as well as increased irritability in the mucous membrane of 
the bladder. The initial dose for a child of five years should be T ^-g- of a 
grain twice daily ; this may be gradually increased to -^V of a grain three 
times a day ; but there is rarely any advantage in pushing it further. 
Ergot is sometimes useful, but rarely gives relief when both strychnine 
and atropine have failed. The indications for its administration are the 
same as for strychnine, but it is objectionable for prolonged use on 
account of the disturbance of the stomach. Ehus aromatica, although 
inferior to the drugs already mentioned, possesses a certain amount of 
value, and may be tried in case the others fail. From three to twenty 
drops of the fluid extract should be given three times a day. Like strych- 
nine, it is indicated in atonic cases. Of the other measures recommended, 
raising the foot of the bed at night to keep the urine away from the neck 
of the bladder, may give temporary relief, as may also some of the various 
contrivances for preventing the child from sleeping upon the back ; but 

* As an illustration of the success which may be obtained by this plan of treatment 
when faithfully carried out, our experience in the New York Infant Asylum may be 
cited. Twelve obstinate cases, in none of which could any local cause be found, were 
selected and treated by Dr. Kerley, then resident physician, in the manner indicated. 
After five months' treatment, seven of the cases were so much improved that inconti- 
nence rarely occurred. The atropine was, however, continued in smaller doses for four 
months longer, at the end of which time the cases were well. In the remaining five 
cases but little improvement was seen after five months' treatment, and not until the 
end of ten months could it be said that much improvement had occurred. In these 
cases the drug was continued for two months longer and all treatment discontinued, as 
the cases were cured. None of these had relapsed six months afterward. It was here 
of great advantage that the children were under close observation in an institution 
where the treatment could be continued. In dispensary and private practice the want 
of early success would no doubt have deterred mothers from continuing the medicine. 



VESICAL SPASM. 649 

none of these are in any sense curative. Some obstinate cases have been 
relieved by galvanism, the positive pole being placed over the lumbar 
spine and the negative pole over the bladder. If there is reason to sus- 
pect a contracted bladder, as when the incontinence has lasted for years 
and the bladder will never hold more than an ounce or two of urine, cure 
is sometimes accomplished by daily distending the organ up to its normal 
capacity with warm water. 

VESICAL SPASM. 

This is quite a common condition, and often passes under the name of 
genital irritation. It is characterized by frequent, sometimes by difficult 
and painful, micturition. It occurs in children of all ages, even in infants, 
but is especially frequent between the ages of two and five years. This 
symptom has already been referred to in connection with uric-acid infarc- 
tions in very young infants. 

The usual cause is the irritation of the bladder by a concentrated, 
highly-acid urine. It often results from cold ; it may accompany acute 
febrile processes, and is sometimes merely a symptom of nervous irrita- 
bility. The cause may thus be in the bladder or in the urine. It may be 
accompanied by enuresis, but usually occurs without it. It is sometimes 
symptomatic of disease in adjacent parts, as in the rectum or the pelvic 
peritonaeum, or it may be associated with inflammation of the vulva or 
urethra. It is also one of the symptoms of vesical calculus. 

The symptoms of vesical spasm are local only. The child passes water 
very frequently, often several times an hour. The accompanying pain 
may be intense, not infrequently sufficient to cause the child to cry out. 
Often there are pain and severe vesical tenesmus with the passage of only 
a few drops of urine at a time, but blood is not present. If the condition 
depends upon the character of the urine, or is only an expression of an 
extreme vesical irritability, the symptoms are generally of short duration, 
possibly a day or two. If it depends upon vesical calculus, it may be 
intermittent. If it is associated with disease of the adjacent pelvic viscera, 
it is inconstant, and may continue for a considerable period, depending 
upon the nature of the cause. 

The treatment, in the ordinary cases, consists in the administration of 
an abundance of water, with alkaline diuretics, and either belladonna or 
hyoscyamus. The following formula is one that I have usually found 
efficient : 

]J Tincturae hyoscyami 3 >s. 

Potassii citratis 3 j 

Aqua) destillat 5 ij 

M. Sig. : Half a teaspoonfnl in water every hour to a child of two years. 

If the cause is outside the bladder, it should receive appropriate 
treatment. 



050 DISEASES OF THE URO-GENITAL SYSTEM. 



VESICAL CALCULI. 

The nucleus of a vesical calculus is usually a renal calculus which has 
passed the ureter, but has been prevented by its size from going farther. 
Stone in the bladder is extremely rare in infancy, probably owing to the 
fluid diet, but it is not infrequent in children from two to ten years of 
age. The most common variety of calculus at this time is the uric acid. 
The other forms, although occasionally seen, are all quite rare. 

The symptoms in children are somewhat different from those in 
adults, and the condition is often overlooked. There is frequently pain 
upon micturition, especially at the end of the act, which may be felt at 
the end of the penis or in the perinasum. There may be a sudden stop- 
page in the flow of urine. The straining often leads to rectal tenesmus 
and even to prolapse. This complication is so frequent that, in a case of 
persistent prolapse, stone should always be suspected. Incontinence of 
urine is a prominent, and often the principal, symptom ; in many cases it 
is noticed only during the day. The urinary changes are not generally 
marked ; hematuria is rare, and mucus and pus are infrequent and in 
small quantity. The genital irritation may lead to the habit of masturba- 
tion. A stone of any considerable size may often be felt by a bimanual 
examination, one finger being placed in the rectum and the other hand 
above the pubes. This is easier in males than in females, but it is not 
very trustworthy, and not conclusive when it gives a negative result. A 
positive diagnosis is made only by exploring the bladder with a sound. 

The treatment of calculus is purely surgical. In young children the 
suprapubic is now generally preferred by surgeons to the perineal opera- 
tion, if the calculus is too small to be easily removed by crushing. 



SECTION VII. 

DISEASES OF THE NERVOUS SYSTEM. 

CHAPTER I. 

INTRODUCTORY. 

The Weight of the Brain. — From ninety-eight observations made in 
the post-mortem room of the New York Infant Asylum, the following 
were the average weights noted : 

At three months 21 oz. (602 grammes). 

At six months 25^ " (712 " ). 

At twelve months 32£ " (916 " ). 

At two years 35 " (990 " ). 

The following are the figures given by Boyd and Schafer : * 



At birth (full term) 

Under three months 

From three to six months .... 
From six to twelve months . . . 

From one to two years 

From two to four years 

From four to seven years 

From seven to fourteen years . 
From fourteen to twenty years 



Males. 


Females. 


Ounces. 


Grammes. 


Ounces. 


Grammes 


11| 


330 


10 


283 


m 


493 


16 


451 


21 


602 


20 


560 


27 


776 


26 


727 


33 


941 


30 


843 


39 


1,095 


35 


990 


40 


1,138 


40 


1,135 


46 


1,301 


40^ 


1,154 


48* 


1,374 


44 


1,244 



At birth the weight of the brain to that of the body is nearly 1 : 8. 
During infancy and childhood the following is the ratio, according to 
Bischoif: during the first year, 1:6; the second year, 1:14; the third 
year, 1 : 18 ; at the fourteenth year, 1 : 15 to 1 : 25 ; in adults, 1 :43. 

The Spinal Cord. — The weight of the cord to the weight of the body 
at birth is 1 : 500 ; in adult life it is 1 : 1500. According to Kolliker, the 
spinal cord and the vertebral column are the same length until the end of 
the third month of foetal life, there being at this time no canda equina. 
At the ninth month the lower end of the cord is opposite the third lum- 
bar vertebra; in the adult it is opposite the first. 



* Quoted by Sachs. 
651 



652 DISEASES OF THE NERVOUS SYSTEM. 

Some Peculiarities in the Diseases of the Nervous System in Infancy 
and Childhood.* — The relatively large size, the rapid growth, and the im- 
maturity of the brain and cord during early life, explain much that is 
peculiar in the nervous diseases of this period. 

At this time, apparently trivial causes are enough to produce quite pro- 
found nervous impressions, because of the instability of the nervous centres 
and the greater irritability of the motor, sensory, and vaso-motor nerves. 
These are conditions which are very much increased by all disturbances of 
nutrition. These disturbances may be manifold in character, but they lie 
at the root of very many of the neuroses of early life, — e. g., extreme nervous- 
ness, disorders of sleep, stuttering, chorea, incontinence of urine, tetany, 
and convulsions. The great liability to convulsions depends not only 
upon the greater irritability of the peripheral nerves, but on the instability 
of the nervous centres and the lack of inhibition over the motor ganglion 
cells of the spinal cord. The nervous centres are more easily exhausted 
than later in life. Prolonged or continuous overstrain from any cause 
whatsoever, frequently leads to headache and chorea, and sometimes even 
to epilepsy and insanity. 

Another peculiarity is the serious consequences which often follow 
reflex irritation, although this is rarely the only factor in the case. 
Conditions which in adult life produce almost no effect may in infancy 
be the cause of most alarming symptoms. As a few examples may be 
cited, reflex symptoms due to phimosis, to intestinal worms, convulsions 
from disturbances of digestion, nervous symptoms due to eye-strain, or to 
adenoid growths of the pharynx. In the production of some of these, 
especially attacks of convulsions, there are several factors, such as the 
great irritability of the peripheral nerves, the instability of the nervous 
centres — often a result of disturbed nutrition, as in rickets — and the lack 
of inhibitory action of the cortex of the brain. 

As a third point of importance may be mentioned the grave permanent 
results which often follow relatively small organic lesions. A good illus- 
tration is seen in the lesions which produce cerebral birth-palsy. Here 
the damage is only in small part the immediate effect of the haemorrhage, 
for this often is not great, but it is the interference with the development 
of certain parts of the cortex that makes this condition so serious. 

From what has been said, it follows that the hygiene of the nervous 
system is of the utmost importance in infancy and childhood. It is 
essential for the healthy development of the nervous system that all 
stimulants should be avoided, — not only tea, coffee, and alcohol, but 
undue and unnatural excitement, the effect of which in infancy is almost 
as serious. A normal development can take place only in the midst of 

* See Rachford ; Some Physiological Factors in the Neuroses of Childhood. Cin- 
cinnati, 1895. 



CONVULSIONS. 653 

quiet and peaceful surroundings, with plenty of time for rest and sleep. 
The conditions of modern life, especially in cities, are such that these 
laws are almost invariably violated, and the consequences of this are seen 
in the marked and steady increase in nervous diseases among children. 



CHAPTER II. 

GENERAL AND FUNCTIONAL NERVOUS DISEASES. 

CONVULSIONS— ECLAMPSIA. 

Uxder this head are included attacks of acute transient nervous dis- 
turbance, characterized by involuntary rhythmical spasm of the muscles, 
either of the face, trunk, or extremities, or all of them, usually accom- 
panied by loss of consciousness. They may be regarded as " motor dis- 
charges " from the cortex of the brain. 

Etiology. — The principal predisposing causes are infancy, conditions 
affecting the nutrition of the brain, and heredity influences. Of all these 
factors, the most important one is the instability of the nerve centres which 
is characteristic of infancy and is associated with the non-development of 
the voluntary centres of the cortex. The brain grows more during the 
first year than in all later life, and this rapidity of growth is in itself an 
important predisposing cause of functional derangement. After infancy, 
attacks of convulsions are much less frequent, and after seven years they 
are relatively rare. While convulsions occasionally occur in children pre- 
viously healthy, the majority of attacks are in those in whom there is at 
least some disturbance of tlie nutrition of the brain, — the cerebral insta- 
bility of infancy being greatly exaggerated by such nutritive disorders. The 
most frequent one is rickets, which may be regarded as altogether the most 
important predisposing cause of infantile convulsions. They are often 
one of the earliest symptoms of that disease, and where convulsions occur 
in infancy without evident cause, rickets should always be looked for. 
Any disturbance of nutrition may predispose to convulsions, such as ex- 
haustion, anaemia, malnutrition, syphilis, and debility resulting from all 
acute diseases, especially those of the digestive tract. Children who in- 
herit from their parents a peculiarly nervous temperament are more liable 
to convulsions than are others. This predisposition is often seen in sev- 
eral members of the same family. Females are rather more frequently 
affected than males. 

The exciting causes include a wide variety of pathological conditions, 
among which disturbances of digestion take the first place. Where the 
susceptibility is very great, the exciting cause may be a trivial one. These 



654 DISEASES OF THE NERVOUS SYSTEM. 

causes may be grouped under three general heads : (1) direct irritation of 
the cortex of the brain ; (2) reflex irritation ; (3) toxic influences. 

Under the head of direct irritation may be included all convulsions 
occurring with the various forms of cerebral disease ; the most frequent are 
meningitis, meningeal or cerebral haemorrhage, tumour, abscess, hydro- 
cephalus, embolism, and thrombosis. As examples of reflex irritation 
may be classed the convulsions following severe injuries, like compound 
fractures or burns, renal or intestinal colic, retention of urine, phimosis, a 
foreign body in the ear, or intestinal strangulation. A case has been re- 
lated to me in which the application of cold to the skin repeatedly induced 
convulsions. Other conditions classed under this head are dentition and 
worms, but both must be regarded as exceedingly rare causes of convul- 
sions. The exciting cause is very frequently the presence in the stomach 
or intestines of undigested food ; such attacks are sometimes ascribed 
to reflex irritation, but the majority are better regarded as toxic. Acute 
and chronic indigestion are to be ranked among the most frequent 
causes of convulsions, both in infants and older children. In either 
there may be but one attack, or attacks may recur at intervals of a 
few months with a repetition of the cause. Of toxic origin may be 
considered not only the convulsions resulting from conditions like 
uraemia and asphyxia, but also those which occur at the onset or in the 
course of various infectious diseases, sometimes classed as febrile con- 
vulsions. They are very frequent at the onset of certain diseases, particu- 
larly pneumonia, scarlet fever, malaria, acute indigestion, and gastro-enteric 
infection ; less frequently of measles, typhoid fever, ileo-colitis, and diph- 
theria. In these cases the convulsions seem due partly to the intensity 
of the poison and partly to the suddenness with which it affects the 
nervous system. . Convulsions occurring late in the course of many diseases 
may be due to toxic influences, especially when associated with exhaus- 
tion of the nerve centres, from the prolonged disturbances of nutrition 
accompanying the febrile condition. 

In pertussis — which, of all infectious diseases, is the one in which con- 
vulsions are most frequent — several factors may be present : asphyxia due 
to a severe paroxysm, cerebral congestion or haemorrhage resulting from 
such a paroxysm, or simply from the peculiar susceptibility of the patient 
brought about by the disease itself. 

Convulsions may be associated with enlargement of the thymus gland. 
I have notes of three cases of fatal convulsions where there was found at 
autopsy great enlargement of this body, which weighed from one to one 
and a half ounces. Two of these infants were previously healthy ; one 
was rachitic. The similarity of all these cases convinced me that the 
convulsions were in some way due to the enlarged thymus, probably from 
pressure either upon the bronchi and lungs, or upon the pneumogastric 
(page 43). < . 



CONVULSIONS. 655 

There are some cases of convulsions for which no cause can be dis- 
covered even at autopsy, and for the present we must be content to class 
them as idiopathic. One attack of convulsions renders the patient more 
liable to a second, and where there have been several, they occur from 
causes which are less and less marked. 

Pathology. — The "nervous discharge " which occurs in an attack of 
convulsions differs in no essential particulars from that of ordinary epi- 
lepsy. In the latter disease there is seen a tendency to recurrence with 
greater or less frequency, until the discharge may take place from very 
slight causes. 

The part of the brain most intimately concerned in the production of 
convulsions is the cortex. Such attacks may be regarded as involuntary 
discharges of nerve force from the cortical motor centres, which result 
from direct irritation of these parts by disease ; or from an irritation aris- 
ing in some other part of the brain, as from the vaso-motor centres of 
the medulla ; or from a reflex irritation in a distant part of the body. 
Convulsions may dejDend upon the fact that while nerve cells may be able 
to generate nerve force they can not control its discharge, as in the con- 
vulsions of rickets. An important element in the convulsions of infancy, 
according to Hughlings Jackson, is the lack of development of the higher 
cerebral functions, in consequence of which they do not exert the control- 
ling influence over the discharge of nerve force which they do in later life. 

The condition of the brain in the beginning of an attack of convul- 
sions is one of anaemia; this is shortly followed by venous hyperemia 
which may be very intense. In infants who die during convulsions the 
brain and its meninges are usually found intensely congested. They may 
be the seat of punctate haemorrhages, and sometimes of more extensive 
ones. The lungs are also deeply congested, and the right heart is generally 
distended with dark clots. The other lesions found are accidental. 

Symptoms. — In some cases prodromal symptoms are present, such as 
extreme restlessness, irritability, slight twitchings of the muscles of the 
face, hands, feet, or eyelids. More frequently, however, the attack comes 
quite suddenly with but momentary warning. Usually the first thing 
noticed is that the face is pale, the eyes fixed, sometimes rolled up in 
their orbits; in a moment or two convulsive twitchings begin in the 
muscles of the eye or face, or in one of the extremities, which usually 
rapidly extend until all parts of the body participate. In most cases the 
convulsions become general, but they may, however, remain unilateral 
even when not due to a local cause, — a point which is often forgotten. 
The contraction of the facial muscles causes a succession of grimaces; the 
neck is thrown back; the hands arc clenched; the thumbs buried in the 
palms; and a quick spasmodic contraction of the extremities occurs. 
There may be some frothing at the mouth, and in all true convulsions 
there is loss of consciousness. Respiration is feeble, shallow, and may be 



056 DISEASES OF THE NERVOUS SYSTEM. 

spasmodic. The pulse is weak ; it may be slow or rapid ; often it is irreg- 
ular. The forehead is covered with cold perspiration. The face is first 
pale, then becomes slightly blue, especially about the lips. Unnatural 
rattling sounds may be produced in the larynx. The bladder and rec- 
tum may be evacuated. The convulsive movements consist in an alter- 
nation of flexion and extension occurring rhythmically. All varieties 
of tonic and clonic spasm may be seen, and in all degrees of severity. 
The contractions of the two sides of the body are usually synchronous. 
After a variable time, from a few moments to half an hour, the convulsive 
movements are gradually less frequent, and finally cease altogether, usually 
leaving the patient in a condition of stupor. They may recur after a 
short time or there may be but one attack. A period of general relaxa- 
tion usually follows the convulsive seizures, frequently accompanied by 
marked evidences of prostration. Transient paralysis, apparently due to 
exhaustion of the nerve centres, is not an uncommon sequel. 

Death may take place from a single attack ; this, however, is rare ex- 
cept in very young infants, especially those who are rachitic. There may 
be no sequel to the convulsions if the cause is a temporary one, or they 
may produce some serious brain lesion, particularly meningeal haemor- 
rhage. Death from convulsions is generally due to asphyxia, or to exhaus- 
tion from the rapidly recurring attacks. Many cases recover in which 
the children for several minutes had the appearance of being moribund. 

One attack of convulsions is very apt to be followed by others ; for 
the occurrence of the first one usually reveals a peculiar susceptibility 
of the nervous system, and each succeeding attack comes from a less 
powerful exciting cause than the previous one. The longer the interval 
which has passed, the less likely is there to be a repetition, especially if 
the child has passed its third year. The number of attacks may be very 
great. In a case recently under the care of Dr. A. M. Thomas and my- 
self, an infant during the latter part of its second year had during six 
months over thirty-five hundred distinct attacks of convulsions. For a 
considerable period they reached the almost incredible number of eighty 
a day, and yet the mental condition of the child in the interval was appar- 
ently normal.* 

Diagnosis. — There can rarely be any difficulty in recognizing an at- 
tack of convulsions. The difficulty consists in determining with which 
of the many possible exciting causes we have to do in the case before us. 
Is it epilepsy ? Does it depend upon cerebral disease ? Does it mark the 
onset of some other acute disease ? Is it reflex, and if so to what is it 



* The post-mortem examination of this case has not yet been completed, but thus 
far there have been found only degenerative changes in the nerve cells of the cortex in 
the motor area and an increase in the neuroglia. These changes existed over quite an 
extensive area, and were more marked upon one side. 



CONVULSIONS. 657 

due ? To answer these questions a careful history must be obtained, and all 
the circumstances surrounding the patient, the character of the convulsions, 
and all the other symptoms present must be taken into consideration. 

In infancy, epilepsy is certainly the least probable diagnosis. In older 
children the most important points indicating that disease are : the pres- 
ence of some of the stigmata of degeneration (page 757), a history of 
previous attacks, a distinct aura preceding the seizure, or a sudden onset 
with a cry or fall, biting of the tongue, a tonic spasm preceding the clonic, 
and, finally, perfect recovery in the course of a few hours after the attack. 
Convulsions which come on with high fever, even though a patient may 
have repeated attacks, are seldom epileptic. However, in some cases only 
prolonged observation can enable one to decide positively whether or not 
epilepsy is present. 

Convulsions occurring in brain disease, except acute meningitis, are 
not as- a rule accompanied by any marked rise in temperature. Focal 
symptoms are often present, such as localized paralysis or rigidity, 
changes in the pupils, and strabismus. The convulsive movements are fre- 
quently limited to one side of the body. It should, however, be borne in 
mind that unilateral convulsions, even when repeated, do not always mean 
a local lesion, as I have seen proved by autopsy more than once. In 
haemorrhage or meningitis, convulsions are likely soon to recur. In tu- 
mour they may recur after a longer interval. 

Convulsions may be thought to indicate the onset of some acute dis- 
ease when they occur in a child over two years old, and when they come 
on suddenly or with only slight premonition in a child previously well; 
but the most important point is that they are accompanied by a high tem- 
perature, — 104° to 106° F. Acute meningitis is the only other condition 
likely to produce these symptoms. Whether the convulsions mark the 
onset of lobar pneumonia, scarlet fever, malaria, or some other disease, 
can be determined only by carefully watching the patient's symptoms for 
twenty-four or thirty-six hours. 

In convulsions depending upon some disorder of the alimentary tract, 
one may get a history of chronic constipation, of improper feeding, and 
in nursing infants sometimes of passion, or even intoxication, in the wet- 
nurse. Convulsions are so frequently due to digestive derangements that 
the condition of these organs should be one of the first things to be looked 
into. 

Examination of, the urine should never be omitted in any case of con- 
vulsions of doubtful origin, even where no dropsy is present. This, both 
in infants and older children, is too often overlooked. Asphyxia may be 
suspected in the case of convulsions occurring in the newly- born, late in 
pneumonia, in some cases of pertussis, in spasmodic or membranous 
laryngitis, or in laryngismus stridulus. Dentition and worms should be 
considered among the least probable, never as the most probable, causes of 
51 



658 DISEASES OF THE NERVOUS SYSTEM. 

reflex irritation, and should not be so accepted without positive evidence. 
Worms are so rare in infancy that at this period they may be practically 
ignored. Dentition seldom, if ever, causes convulsions except in patients 
who are markedly rachitic. In all cases of convulsions of doubtful or 
obscure origin occurring in infants, rickets should be suspected as the 
underlying cause, and the child carefully examined for other evidences of 
that disease. 

Prognosis. — This depends upon the age of the patient and the cause 
of the convulsions. Idiopathic or reflex convulsions are rarely dangerous 
to life except in very young or in rachitic infants. In such patients death 
from convulsions is not at all uncommon. Convulsions occurring at the 
onset of acute febrile diseases are seldom fatal, and not often serious ; 
they may not even indicate an unusually severe type of the disease. Espe- 
cially fatal are the convulsions of pertussis and of asphyxia when they 
occur late in any form of laryngeal or pulmonary disease. In nephritis, 
while always serious, convulsions are by no means invariably fatal. The 
conditions during an attack which should lead one to make a bad prognosis 
are when the convulsions are prolonged or recur frequently ; also the pres- 
ence of very great prostration, a feeble pulse with cyanosis, or deep stupor. 

In the prognosis one must take into account not only the immediate 
result of the attack, but its possible outcome. Except where convulsions 
mark the beginning of epilepsy, they are much less serious than they are 
generally supposed by the laity. In a highly nervous or susceptible child 
a convulsion may often mean no more than an attack of severe migraine 
in an older person. Such are undoubtedly most of the attacks seen in 
practice. Permanent injury to the brain, simply as a result of an attack, 
although possible, is still rare. But when convulsions are repeated the 
development of epilepsy is to be feared. There is little doubt that some 
cases of epilepsy have their origin in attacks of convulsions, which in the 
beginning were the result simply of digestive derangements ; by a constant 
repetition of the exciting cause the convulsive habit finally becomes estab- 
lished. This possibility is therefore to be borne in mind in all cases 
where children have had several convulsions, although it is unusual that 
this result is seen. The farther apart the attacks are and the more defi- 
nite the exciting cause, the less likely is this to be the case. 

Treatment. — Summoned to a child in convulsions, it is a physician's 
duty to go at once and remain with the patient until the attack has sub- 
sided. He should take with him chloroform, a hypodermic syringe with 
morphine, and a solution of chloral. In order to treat convulsions intelli- 
gently one must have in mind the prominent pathological conditions. 
These are acute cerebral hyperemia, a more or less severe asphyxia with 
pulmonary congestion, an overtaxed right heart, and in fact a tendency 
to congestion of all the internal organs. The nervous centres are in a con- 
dition of such unnatural excitability that the slightest irritation may bring 



CONVULSIONS. 659 

on convulsive movements when they have temporarily subsided. The 
patient should therefore be kept perfectly quiet, and every unnecessary dis- 
turbance avoided. Cold should be applied to the head — best by means of 
an ice cap or cold cloths — and dry heat and counter-irritation to the surface 
of the body and extremities. The time-honoured mustard bath causes so 
much disturbance of the patient that it may well be dispensed with and the 
mustard pack (page 52) substituted. The feet may be placed in mustard 
water while the child lies in its crib. The mustard pack and footbath 
should be continued until the skin is well reddened. The degree to which 
counter-irritation of the skin should be carried will depend upon the con- 
dition of the pulse and the cyanosis. 

In controlling convulsions the three remedies which may be depended 
upon are the inhalation of chloroform, morphine hypodermically, and 
chloral by the rectum. Chloroform is undoubtedly the most reliable 
remedy for an immediate effect, and should be used even in the youngest 
infant. At the same time that it is being administered, chloral should 
be given per rectum. The initial dose should be, at six months, four 
grains ; at one year, six grains ; at two years, eight grains, dissolved 
in one ounce of warm milk. It should be injected high into the bowel- 
through a catheter, and prevented from escaping by pressing the buttocks 
together. It may be repeated in an hour if necessary. The effect of the 
drug is generally obtained in twenty minutes. If, in spite of the chloral, 
the convulsions show a marked tendency to continue as soon as the chloro- 
form is withdrawn, or if the enema of chloral has been expelled, morphine 
should be given hypodermically. Where the heart's action is weak, this 
is probably the best of all remedies. Objections are urged against it only 
by those who have had no experience with its use. To a well-grown child 
two years old, fa of. a grain may be given ; one year old, -fa of a grain ; 
six months old, -} E of a grain. This dose may be repeated in half an 
hour if no effect is seen. The tolerance of opium in cases of convulsions 
is very marked, and sometimes double the doses mentioned may be re- 
quired. The only other agent of much value is oxygen. I have seen con- 
vulsions which continued in spite of all other means, yield immediately 
to oxygen. This is most likely to be valuable in cases of convulsions due 
to asphyxia. 

When once under control, the recurrence of the convulsions may be 
prevented by keeping the patient for two or three days under the influ- 
ence of chloral with bromide of sodium, the amount of chloral being 
gradually reduced. If it is badly borne by the stomacli and not easily re- 
tained by the rectum, either antipyrine or phenacetine may be used with 
the bromide. Where there is a strong tendency to recurrence of the con- 
vulsions, urethan is sometimes even more efficient than chloral. It may 
be given in the same or in slightly larger doses. 

As soon as the convulsions have ceased, the cause should be sought 



660 DISEASES OF THE NERVOUS SYSTEM. 

and treated. In infancy it is wise in every case to irrigate the colon thor- 
oughly with warm water, to remove any possible source of irritation. If 
there is reason to suspect the presence of indigestible food in the stom- 
ach, this may be washed out. Much more frequently it is in the intestines, 
and free purgation by calomel is advisable. If there is high temperature, 
this should be reduced by the cold bath or pack. Secondary attacks are 
to be prevented by careful feeding, by improving the general nutrition 
by means of fresh air, iron, cod -liver oil, and phosphorus. The last two 
are especially valuable in cases due to rickets. 

EPILEPSY. 

Epilepsy may be defined as a disease in which there is an established 
disposition to convulsions of a certain type, with loss of consciousness, 
which have recurred until a habit of convulsions has become fixed.. 

A distinction must be made between cases of so-called " idiopathic " 
epilepsy and those which are secondary to a definite lesion of the brain, 
such as tumour, sclerosis, or abscess. Convulsions of the latter character 
are designated as " symptomatic " epilepsy, and are discussed in connection 
'with the various diseases in which they occur. The nature of the attack 
may, however, be identical in both varieties, and may not differ from an 
ordinary attack of convulsions or eclampsia. 

The proportion of idiopathic cases in children is not so large as was 
formerly supposed ; for many of these have been shown to depend upon 
lesions once overlooked, particularly infantile cerebral paralyses of a mild 
type. 

Etiology. — From a consideration of 1,450 cases of epilepsy, Gowers 
states that 12 per cent begin in the first three years of life, and 46 per cent 
between ten and twenty years. The greatest tendency to the development 
of the disease is shown about the time of puberty. Females are rather 
more liable to be affected than males, although the difference in sex is 
slight. Heredity plays an important role in the production of the disease. 
In one third of the cases, according to Gowers, there is a family history 
either of epilepsy or insanity. Not infrequently more than one child in 
the family is affected. All hereditary nervous diseases predispose to epi- 
lepsy, but it is a question whether other hereditary diseases have any 
special influence. 

Not very infrequently epilepsy may be traced to convulsions occurring 
during infancy. In what proportion of the cases this is true it is impossible 
to state with accuracy. Infantile convulsions are very common, and usu- 
ally the cause which produces them is a transient one. The proportion of 
such cases which develop epilepsy later in life is certainly small. In the 
second and third years, however, the occurrence of convulsions not infre- 
quently marks the beginning of true epilepsy. Given a strong predispo- 
sition to epilepsy, it is easy to see how rickets may have been the exciting 



EPILEPSY. 661 

cause of the early convulsions, which may have been the first of the 
epileptic series. The first seizure is sometimes traceable to fright, great 
excitement, heat-stroke, or blows or falls upon the head even without 
any gross lesion. It may follow any of the acute diseases of childhood, 
particularly scarlet fever, rarely measles or typhoid. In none of these, 
however, is it often seen. As reflex causes may be mentioned intestinal 
worms, phimosis, adenoid vegetations of the pharynx, delayed or difficult 
menstruation, and masturbation. Most of these are rare causes, but they 
may be sufficient to produce the disease where a strong predisposition 
exists. Syphilis may be the cause of epilepsy even when there is no local 
disease of the brain. 

Among the most important factors in producing a paroxysm, is intes- 
tinal putrefaction associated with chronic constipation and chronic intes- 
tinal indigestion. This subject has been lately investigated with great 
care by Herter and Smith,* who studied 238 specimens of urine from 31 
epileptics. In 72 per cent of their observations there was unmistakable 
evidence of excessive intestinal putrefaction, as shown by the presence 
of ethereal sulphates in the urine in large amount, just before the occur- 
rence of the paroxysm. The inference seems warranted that this intestinal 
condition was closely connected with the epileptic seizures. The state- 
ment of Haig, that there is an excessive elimination of uric acid preceding 
the paroxysm, was not borne out by the observations of Herter and Smith. 
The association of intestinal putrefaction with seizures of epilepsy is very 
important as furnishing a clew to the management of many of these 
cases. I believe it to be one of the most important etiological factors in 
cases occurring in children, particularly as an exciting cause of the first 
attacks. 

Pathology. — It is not within the scope of this work to discuss the 
various theories which have been advanced. The following are the con- 
clusions reached by Gowers: f 

" The muscular spasm is to be regarded as the result of the sudden 
overaction (discharge) of nerve cells, the violent liberation of nerve force, 
and the sensations which the patient experiences before losing conscious- 
ness must be due directly or indirectly to the same cause. The disease 
which excites convulsions is most frequently at the cortex, and when 
organic disease causes convulsions that begin locally, the disease is almost 
invariably at the cortex. In idiopathic epilepsy the convulsions some- 
times begin in this way, and this suggests very strongly that in such cases 
the change occurs in the cortex. Epilepsy must then be regarded as a 
disease of the gray matter, most frequently of the gray matter of the 
cortex." 



* New York Medical Journal, August and September, 1892. 
f Diseases of the Nervous System, American ed. 1888, p. 1098. 



662 DISEASES OF THE NERVOUS SYSTEM. 

While there is pretty general agreement that the seat of the morbid 
changes in true epilepsy are in the cortex, but little is yet definitely 
known as to the nature of these changes. Van Gieson has published * 
some very careful observations made upon portions of the cortex removed 
at a surgical operation from two epileptic patients. In one of these the 
disease was primarily due to a foreign body ; in the other, to an old cica- 
trix. The conditions found represent the earlier changes of the disease, 
and were essentially the same in both cases. There were degenerative 
changes in certain of the ganglion cells, which in places had resulted in 
almost complete dissolution of these cells. In addition there was a distinct 
hyperplasia of the neuroglia tissue. Diffuse neuroglia sclerosis starting 
from the focus of disease has been reported by certain French writers — 
Marie, Fere, and Ohaslin. 

Symptoms. — Two distinct types of epileptic seizures are met with : the 
major attacks, or grand mal, in which there are severe convulsions lasting 
from two to ten minutes, with loss of consciousness, etc. ; and minor 
attacks, or petit m.al, in which the convulsive movements are slight and 
may be absent, and in which the loss of consciousness is often but mo- 
mentary. Between these two extremes all gradations are seen. 

Grand mat — The onset may be sudden, without premonition, or it 
may be preceded by certain prodromal symptoms known as the aura. 
The aura may be motor, such as a local spasm of the hand, face, or leg ; or 
sensory, such as numbness and. tingling in any part of the body, or some 
abnormal sensation rising gradually to the head, at which time loss of 
consciousness occurs. The variety of sensations described by patients as 
indicating an attack is endless. There may be a sensation in one finger, 
in the face, tongue, eye, or in any part of the body ; or the warning may 
be of a general character, like a tremor or a shivering sensation, or a feeling 
of faintness. There has also been described a visceral or pneumogastric 
aura, in which there is epigastric pain, sometimes nausea, and a sensation 
of a ball in the throat ; or there may be palpitation, or cardiac distress. 
There may be general giddiness or vertigo, or a sensation of fulness in 
the head ; or feelings of strangeness, or a dreamy, dazed condition ; and, 
finally, the aura may have reference to any of the special senses, most 
frequently to sight. Sparks may appear before the eyes, or flashes of light 
or colour, or strange objects may be seen ; or there may be a momentary 
loss of hearing ; or strange sounds may be heard. In most cases the aura 
is peculiar to the individual, whose attacks are likely to be preceded by 
the same symptoms. 

At the beginning of the seizure the face becomes pale, the pupils 
widely dilated, the eyes rolled up in their orbits and fixed. Speedily there 
is loss of consciousness. Simultaneously with these symptoms, or imme- 

* New York Medical Record, April 24, 1893. 



EPILEPSY. 663 

diately following them, there occurs a violent tonic spasm to which are 
due the characteristic symptoms of the early part of the seizure — viz., the 
fall, cry, biting of the tongue, cyanosis, and evacuation of the bladder or 
rectum. The fall is forcible, violent ; in fact, the patient is precipitated 
usually forward, and frequently suffers injury, never sinking down as in a 
faint. The head is often strongly rotated to one side. The position of the 
hands is that assumed in tetany. The cry is a hoarse, inarticulate sound, 
not very loud, and is due to forcible expiration, owing to spasm of the 
muscles of respiration with the glottis partly closed. The cyanosis is the 
result of tonic spasm of the muscles of respiration ; it may be quite intense, 
so that the face is livid, bloated, and the features distorted. The spasm 
of the muscles of mastication causes the biting of the tongue. Evacuation 
of the bladder and rectum may result from contraction of their walls, or 
from spasm of the abdominal muscles. The violence of the muscular 
spasm in this stage may be very great ; it has caused fracture of bones, 
rupture of muscles, and even dislocation of joints. 

The stage of tonic spasm may be only momentary, the patient passing 
almost at once into the stage of clonic convulsions. The usual duration 
is from ten seconds to half a minute. In the stage of clonic spasm which 
follows, the symptoms are those of an ordinary attack of convulsions. The 
muscular contractions are violent, and there is often frothing at the 
mouth. Gradually the muscles of respiration relax, air enters the chest, 
and the cyanosis passes off. After the clonic spasm has continued for a 
variable time — from two or three minutes to half an hour — the muscular 
contractions become less and less frequent, and finally cease altogether. 
In a few minutes the patient may regain consciousness, look vacantly 
around, and in a dazed way perhaps ask what has happened, he being com- 
pletely oblivious to all that has occurred. More frequently, however, he 
passes at once into a deep sleep, which continues for an hour or more, 
but from which he can be aroused. From this he usually wakens with a 
severe headache, which may continue for several hours. After this he often 
feels better than for several days preceding the attack. During the seizure 
the temperature may be elevated one or two degrees, but rarely more. 
The attack may be followed by a slight temporary paresis, or aphasia, 
hysterical phenomena, vomiting, and intense hunger. In very rare cases 
the urine may contain a trace of sugar. 

Petit mal. — The minor attacks of epilepsy may. present a very great 
variety of symptoms, and at times it is almost impossible to decide that 
these are epileptic, except from their periodical occurrence. They pass 
under the names of "spells," " attacks of dizziness," " fainting turns," etc. 
The most striking thing which stamps them as epileptic is the loss of con- 
sciousness, and this may be of short duration, sometimes only momentary, 
and so pass unnoticed. In some cases it is absent altogether. There is 
no fall, but there may be a slight dropping of the head, a fixed stare for a 



664 DISEASES OF THE NERVOUS SYSTEM. 

moment or two, and that is all. This may or may not be preceded by an 
aura. After such a mild attack the patient's mind may be somewhat 
confused, and he may do or say strange things. All sorts of curious acts 
have been performed in an automatic way by patients in the condition 
which follows an attack of epilepsy, which may perhaps be regarded as 
part of the attack. In rare instances even acts of violence may be done. 

The mental condition of epileptics. — In this connection a careful dis- 
tinction must be made between cases in which epilepsy is secondary to 
some organic brain disease, such as infantile cerebral palsy, which may 
itself be a cause of mental impairment, and the mental disturbances seen 
in cases of idiopathic epilepsy. The children who are the subjects of the 
latter disease, and who are perfectly normal mentally, are certainly few. 
All degrees of disturbance may be seen, from those who are simply dull, 
apathetic, backward in development, and uncontrollable in temper, to 
those who are melancholic, idiotic, and even maniacal. The earlier in 
childhood epilepsy develops, the greater is usually the mental disturbance 
seen, because of the effect of the seizures upon the brain during its period 
of active growth. Speech and all mental development may be greatly re- 
tarded. The more frequent and more severe are the attacks, the more 
marked are the mental symptoms present. 

Symptomatic epilepsy. — This occurs most frequently in children as a 
sequel of cerebral palsy, usually with hemiplegia, and it may follow either 
the congenital or acquired form. Epilepsy may come on at any time after 
the onset of the paralysis — from a few months to five or six years. At 
first the attacks may be separated by long intervals, but- they gradually 
become more frequent as time passes. The convulsions in post-hemiplegic 
epilepsy begin, as a rule, on the paralyzed side, and for a long time they 
may be confined to that side ; but later they may become general, in which 
cases they are indistinguishable from attacks of idiopathic epilepsy. Se- 
vere seizures are more likely to be seen than are the mild ones. 

Course of the disease. — This is extremely irregular. In most cases 
seizures at first occur at long intervals, of perhaps a year, but later they 
become more and more frequent. Either the mild or the severe attacks 
may be first seen, and may remain throughout as the ouly type present, or 
they may be associated in the same case. There are most frequently seen, 
occasional major attacks with a large number of minor ones. The inter- 
val between the epileptic seizures in most cases is from two to four weeks, 
although they may be of daily occurrence. Sometimes three or four 
seizures will follow one another closely, and then there will occur a long 
interval of immunity. The seizures may come on either during sleep or 
in the waking hours, and in some cases for a long time they may occur 
only in sleep. Such cases present peculiar difficulties in diagnosis, and 
are often long unrecognised as epileptic. The general health of patients 
may be quite normal. 



EPILEPSY. 665 

Death rarely, if ever, results from epilepsy, except from some acci- 
dent at the time of the seizures, or from the condition known as the 
status epilepticus ; in this the attacks come on with great frequency and 
severity, the patient at times passing rapidly from one convulsion into 
another, the temperature rising to 105° or 106° F., and death occurring 
either from exhaustion, owing to the severity of the convulsions, or from 
coma. 

Diagnosis. — In most cases there is little difficulty in recognising the 
major attacks when they occur by day. Nocturnal attacks may be diag- 
nosticated by the cry, the biting of the tongue, blood upon the pillow, 
sub-conjunctival extravasation, evacuation of the bladder or rectum, and 
the severe headache. Minor attacks present the greatest difficulties, and 
a positive diagnosis is often impossible until the patient has been watched 
for a long time. The most important points to be noted are sudden 
pallor, dilatation of the pupils, temporary loss of consciousness, or sim- 
ply mental confusion, and sometimes the evacuation of the bladder. 
The duration of the attack is shorter than is usual in an ordinary faint. 
The difficulty of distinguishing epilepsy from hysteria rarely occurs in 
childhood. 

It is not always possible to distinguish between secondary or symp- 
tomatic epilepsy and the idiopathic or hereditary form, particularly if the 
case comes under observation late in the course of the disease. The points 
which go to establish the first form are : that the convulsive movements are 
partial, or limited to one side ; that when they are general, they always 
begin in the same part of the body ; or that there is a history of partial or 
unilateral attacks for some time before the occurrence of any general 
convulsions. It is important in all cases to examine the patient care- 
fully for signs of an old hemiplegia, the symptoms of which may be so 
slight as to be readily overlooked. A marked increase in the reflexes of 
one side is, according to Sachs, quite as conclusive evidence as a distinct 
weakness of the arm or leg. In idiopathic epilepsy some of the stigmata 
of degeneration (page 758) are usually present. The sudden development 
of epileptic seizures in a child previously healthy, and in whom there is 
no hereditary history of the disease, should always arouse the suspicion of 
organic brain disease, especially tumour ; and if there are besides, severe 
headache, vomiting, and optic neuritis, the existence of tumour is reason- 
ably certain. 

Prognosis. — The danger to life in epilepsy is very slight. Death is 
generally due to some accident, particularly drowning, at the time of a 
seizure. The' tendency to spontaneous cessation of the attacks is small, 
while the tendency to recurrence is very great. 

The prognosis in any given case depends upon the cause of the disease 
and the duration of the symptoms. Where the cause can be removed, 
and where the symptoms have lasted less than a year, the prospects of per- 



QQQ DISEASES OF THE NERVOUS SYSTEM. 

manent cure are fairly good. This is particularly true of cases in which 
the epilepsy clearly depends upon gross errors in diet, with chronic intes- 
tinal indigestion. In such cases, if the patient can be placed under proper 
control and dietetic measures well carried out, the development of chronic 
epilepsy can be arrested in a considerable number of cases. If, on the 
contrary, the hereditary tendency to the disease is marked, if the epileptic 
seizures have developed apart from any adequate exciting cause, and if 
they have continued untreated or in spite of treatment for two or three 
years, the symptoms may perhaps be relieved, but there is no prospect 
whatever of permanent cure. In the cases also which are due to local irri- 
tation, like that resulting from an old meningeal haemorrhage, the prog- 
nosis is invariably bad, and only temporary relief is to be expected. A 
few cases of traumatic epilepsy have been cured and many have been 
greatly improved by a surgical operation. 

Treatment. — The first indication is to remove the cause where one can 
be found. If in the male phimosis exists, or other evidence of genital 
irritation, circumcision should be done, or the prepuce retracted and ad- 
hesions broken up. Adenoid growths of the pharynx should be removed, 
and likewise every other cause of reflex irritation. Particular attention 
should be given to the digestive organs. The most hopeful cases are those 
associated with acute and chronic disturbances of digestion, especially 
chronic intestinal indigestion with constipation. These cases are to be 
managed like others of the same sort in which epileptic attacks are not 
present (page 368). Meat should be allowed once a day and in mod- 
erate quantity. Milk should be given, diluted if necessary, also kumyss 
and matzoon. Green vegetables, except peas and beans, may be given 
freely ; also all fresh fruits. Tea, coffee, and alcohol in every form must 
be absolutely prohibited ; also potatoes and oatmeal. The most careful 
attention should be given to the bowels. Under no circumstances should 
a condition of chronic constipation be neglected. A dose of calomel 
once a week and intestinal irrigation two or three times a week are of 
great value in many cases. Where the symptoms of intestinal putrefac- 
tion are marked, borax is at times of decided value — two grains three 
times a day to a child of five years — or salicylate of sodium, salol, or the 
benzoate of sodium may be given ; the dose of each being from two to 
ten grains, according to the age of the child, after each meal. The gen- 
eral hygiene of the patient must receive careful attention. He must lead 
a simple, regular life, as much as possible out of doors, away from the ex- 
citements of a large city, or from association with many children, and in 
short the nervous system should be kept as quiet as possible. 

All the foregoing means of treatment are of equal importance with the 
use of specific drugs. The most common mistake is to rely only upon 
drugs, ignoring the other measures mentioned. It not infrequently hap- 
pens that drugs are without any avail when they are the only means of 



EPILEPSY. 667 

treatment employed, whereas in conjunction with other measures marked 
improvement is seen. 

The bromides are unquestionably the best means of combating the epi- 
leptic habit. Either the sodium salt alone or a combination of the sodium 
and ammonium bromides is to be preferred. The purpose should be to 
give the smallest doses which will control the seizures. Children require 
proportionately larger doses than adults, and in most cases a child of five 
years will need from twenty-five to fifty grains a day. Seguin's * method 
of administering the bromides is largely followed in New York, and is of 
great value. It is to give the larger part of the quantity for twenty-four 
hours, shortly before the time when the seizures have usually occurred ; in the 
interval to give much smaller doses, and in all cases to give the dose largely 
diluted, — in from six to eight ounces of water. He gives a dose early in the 
morning, and, where the seizures are apt to come at night, one at bedtime. 

Cases of petit mal are especially difficult to control. For such there is 
often an advantage in combining belladonna with the bromides. In all 
cases the treatment must be continued for a long time if anything is ac- 
complished. The bromide should be gradually reduced after the attacks 
are controlled, but must be given in moderately large doses for at least 
two years after the seizures have ceased. The addition of borax seems 
occasionally better than the bromides alone in cases where there is ex- 
cessive intestinal putrefaction. Sometimes the combination of chloral or 
antipyrine with bromides is advantageous, particularly if the latter are 
badly borne or cause an anuoying amount of acne. Seguin states that he 
has been able to control the acne in many cases by giving at the same 
time moderate doses of arsenic. Other drugs occasionally useful as adju- 
vants to the bromides are strychnine and digitalis. 

The surgical treatment of epilepsy has of late attracted much atten- 
tion. An operation is to be considered in cases in which the paroxysms 
are very frequent and severe, and when there is present a definite local 
cause, such as an old fracture of the skull, or where epilepsy has followed 
an injury to the head even without fracture. Sachs sums up the present 
status of this question as follows : " In a case due to a traumatic or organic 
lesion an early operation may prevent the development of cerebral sclerosis. 
If early operation is not done, the occurrence of epilepsy is a warning that 
secondary sclerosis has been established and an operation may prevent it 
from increasing. Operation must include the removal of the diseased 
area ; here, if all other parts are normal, a cure may result. Under favour- 
able conditions a few cases of epilepsy may be cured by surgery and many 
more improved." 

The education of epileptic children is a subject of great difficulty and 
is often neglected. There are many reasons why it is impracticable to 



* New York Medical Journal, March 89, 1890. 



068 DISEASES OF THE NERVOUS SYSTEM. 

send them to ordinary schools, and it is very desirable that special schools 
for them should be established. 

The management of the attach. — Abortive measures are sometimes 
successful in cases with a distinct aura, the most reliable being the inhala- 
tion of nitrite of amyl. While the seizure lasts, the patient should be 
prevented from ' injuring himself. The clothing should be loosened, a 
spool or cork should be placed between his teeth to protect the tongue, 
but no effort made to restrain his movements unless he is liable to do vio- 
lence to himself. An epileptic child should never be without some com- 
panion. 

TETANY. 

This is a condition characterized by tonic muscular spasm, which may 
be intermittent or continuous. It usually affects the muscles of the ex- 
tremities, especially the hands and feet, more rarely the neck, face, and 
trunk. When limited to the hands and feet it is known as carpo-pedal 
spasm or arthrogryposis ; and although sometimes classed separately, this 
seems to be really only one manifestation of the same general condition. 
In infants, tetany is very frequently associated with laryngismus stridulus, 
this being present in fully two thirds of the cases ; but in older children 
this association is quite rare. General convulsions occur in from twenty 
to thirty per cent of the cases. Tetany is rare in this country, as shown 
by the fact that Griffith * in 1895 could find reported only fifty cases, of 
which thirty-eight were in children. 

Etiology. — While tetany may occur at any age, it is most frequent in 
infancy. Of eighty-seven cases reported by Barthez and Sanue, fifty per 
cent were observed in the first two years, twenty per cent from three to 
six years, and twenty-five per cent from twelve to fifteen years. Of the 
cases in children collected by Griffith, sixty-six per cent were under two 
years of age. In infancy males are much more frequently affected ; but 
when the disease occurs in older children, females seem much more liable 
to it. Tetany rarely occurs as a primary disease. It is most frequently 
associated with rickets ; in fact, rickets is almost invariably found in the 
infantile cases. It sometimes occurs with chronic diarrhoea and with 
marasmus. It has been known to follow broncho-pneumonia, pertussis, ty- 
phoid fever, rheumatism, and measles. Of the exciting causes, the most 
frequent one is some irritation in the gastro-enteric tract. This may be 
the products of chronic indigestion, or of acute diarrhoea, worms, and 
sometimes even intussusception. Attacks in older children are frequently 
ascribed to cold. In girls, tetany may occur at the time of puberty, espe- 
cially where menstruation is delayed ; it has followed removal of the 
thyroid gland ; and it has been known to occur epidemically in much the 
same way as chorea. 

* American Journal of the Medical Sciences, February, 1895. 



TETANY. 669 

Pathology. — Up to the present time no constant anatomical lesions 
have been demonstrated in tetany. The circumstances in which it occurs, 
its symptoms and course, all indicate that it is a neurosis probably depend- 
ent upon disturbances of nutrition in the nerve cells of the spinal cord 
and medulla. 

Symptoms. — The spasm may occur quite suddenly, or it may be pre- 
ceded by various sensory disturbances, such as pain, numbness, or ting- 
ling. The upper extremities are usually first affected, the spasm grad- 
ually becoming more severe and finally involving the lower extremities. 
Both sides of the body are equally affected. The position assumed by the 
hands is very characteristic : The fingers are flexed at the metacarpo- 
phalangeal joint and the phalanges extended ; the thumbs are adducted al- 
most to the little finger ; the wrist is flexed at an acute angle, and the 
whole hand drawn somewhat to the ulnar side (Fig. 108). No motion is 
allowed at the wrist, but movements at the elbow and shoulder are usually 
normal. The feet are strongly extended, sometimes in the position of typical 
equino-varus. The first phalanges of the toes are flexed, and the second 
and third rows extended ; the plantar surface is strongly arched, and the 
dorsum of the foot is very prominent, standing out like a cushion. The 
typical position of the feet is well shown in the accompanying illustration. 
There are rigidity of the muscles of the calf and tension of the plantar fas- 
cia. The tendo-Achillis stands out prominently. Motion at the hip and 
knee is generally free. The spasm in many cases is limited to the hands 
and feet ; more rarely the muscles of the thigh, usually the adductors, may 
be involved. f I have seen three or four cases in which the spasm affected 
only the cervical muscles, producing marked opisthotonus. This form is 
generally mild, and may be associated with marasmus. In very rare cases 
the muscles of the trunk, the face, or the eye may be involved. 

Where the spasm is intermittent, and in some cases where it has sub- 
sided, it may be excited by making pressure upon the large nerve trunks 
and arteries of the parts affected. This is known as " Trousseau's symp- 
tom," and is characteristic of the disease. 

Pain owing to the spasm is frequently present. It is usually sharp and 
lancinating, and may be so severe as to cause children to cry out. Pain 
is induced by any attempt to overcome the spasm, and sometimes it is con- 
stant. Other disturbances of sensibility are even more common than 
pain. There is no loss of consciousness and no fever. The spasm is gen- 
erally continuous, although there may be periods of remission or even of 
intermission. When associated with laryngismus stridulus, the spasm is 
much increased during these attacks. The electrical reactions are as a rule 
increased, and the knee-jerk and cutaneous reflexes are exaggerated. 

The duration of the disease is from a few days to several weeks. The 
mild form, which is usually seen in infants, in most cases passes away 
spontaneously in two or three weeks, although there may be relapses and 



670 



DISEASES OF THE NERVOUS SYSTEM. 



second attacks at variable intervals. The most important complication 
is general convulsions. These may come on at any time in the course of 




Fig. 108.- 



-Tetany, showing the characteristic position of the hands and feet, in a child two 
years old. 



the disease. Spasm of the glottis may either precede or follow tetany. 
When associated they generally cease at the same time. Slight paralysis 
may follow or alternate with the spasm. 

Diagnosis. — The diagnostic feature of the disease are bilateral spasm — 
in infants usually limited to the hands and feet — without loss of conscious- 
ness, the spasm being increased or excited by pressure upon the nerves,' 
exaggerated reflexes, and the presence of some previous disease, especially 



LARYNGISMUS STRIDULUS. 671 

rickets or some disorder of the intestines. The severe form may be mis- 
taken for tetanus ; but this is very rare except in the newly-born ; and 
trismus is the rule, and generally it is the first symptom. Trismus is 
extremely rare in tetany. From meningitis, tetany is distinguished by 
the absence of cerebral symptoms ; from cerebral tumour, by the bilateral 
character of the spasm, the absence of headache and focal brain symp- 
toms ; from haemorrhage, by the absence of cerebral symptoms ; from 
malarial spasm, by the fact that it is constant, not intermittent. 

Prognosis. — Tetany per se is not fatal, but death may result from the 
development of general convulsions or from the original disease which 
tetany complicates. Recovery is usually perfect, although Gowers states 
that in rare cases it has been followed by muscular atrophy. 

Treatment. — The first indication is to remove the cause, and this in 
most cases is found in the digestive tract. If rickets is present it should 
receive the usual treatment, both dietetic and medicinal. If worms are 
suspected a vermifuge should be given. For the relief of the spasm, the 
hot bath is a most valuable remedy ; friction may also be employed. Drugs 
which have the power of allaying spasm should be given, — chloral, bromides, 
and antipyrine. In the event of failure by these methods galvanism may be 
tried. After the attack the child's general nutrition should receive careful 
attention, to prevent relapses. 

LARYNGISMUS STRIDULUS— SPASM OF THE GLOTTIS. 

Idiopathic spasm of the glottis, or laryngismus stridulus, is a rather rare 
disease, and belongs especially to infancy. It is a pure neurosis, not often 
seen except in children who are rachitic. It is frequently associated with 
carpo-pedal spasm and with general convulsions. The disease is not to be 
confounded with ordinary spasmodic croup or catarrhal spasm of the 
larynx, which is of very frequent occurrence. 

Spasm of the larynx may be seen in several conditions quite different 
from laryngismus stridulus. It forms one of the essential features of per- 
tussis. It occurs both in infants and in older children from pressure upon, 
or irritation of, the pneumogastric or recurrent laryngeal nerve by a tumour 
in the mediastinum, — usually a tuberculous lymph node, or retro-cesophageal 
abscess. Keflex spasm of the larynx is also associated with enlarged ton- 
sils, adenoid growths of the pharynx, and elongated uvula. There is 
a form of reflex spasm which occurs in the newly-born accompanied by 
crowing inspiration ; this is not frequent, and is rarely serious. 

Idiopathic spasm of the larynx is quite different from any of these. It 
is peculiar to infancy, the great proportion of cases occurring between the 
sixth and eighteenth months. Mules appear to be more susceptible than 
females. The constitutional condition with which it is usually associated 
is rickets. In a large number of cases, but not in all, there is cranio-tabes. 
Many writers believe that laryngismus is invariably of rachitic origin. Of 



672 DISEASES OF THE NERVOUS SYSTEM. 

fifty cases observed by Gee, there were found in all but two unmistakable 
evidences of rickets. The disease occurs in delicate infants who have 
been closely confined in warm rooms, and it is probably on this account 
that it is more often seen in the winter and spring than at other seasons. 
The exciting causes of this spasm may be a breath of cold air, or any form 
of nervous excitement, such as fright or crying. Sometimes it is induced 
by swallowing, and it may be traced to indigestion or constipation. 

Pathology. — There are no anatomical changes in this disease. It is a 
pure neurosis, and it is generally believed to be of central origin, depending 
essentially upon imperfect nutrition of the motor centres of the spinal 
cord and medulla. 

Symptoms. — The disease is often unnoticed by the parents until the 
attacks have become quite frequent, the first ones being mild, and the later 
ones more and more severe. Occasionally the very first paroxysms may be 
severe. The attack comes on suddenly. The child throws back its head, 
the face becomes pale, then livid, and for the time there is complete arrest 
of respiration. This continues for a few moments, during which the 
cyanosis deepens, and the child seems in great distress, making violent 
efforts to breathe. If the paroxysm is a severe one, the asphyxia may 
be so great as to lead to loss of consciousness, and it may even be fatal, or 
the attack may terminate in general convulsions. In milder attacks, 
after fifteen or twenty seconds the muscular spasm relaxes, the glottis 
opens, and a long, deep inspiration occurs, with the production of a crow- 
ing sound. Such attacks may occur as frequently as every fifteen or 
twenty minutes, or there may be only six or eight during the day. Be- 
tween them the condition of the child may be normal, or carpo-pedal 
spasm may be present. It is important to note that in this disease 
there is not a stridor due to narrowing of the glottis, as in ordinary 
croup, but a condition of apnoea from its complete closure. Not all the 
paroxysms in the same case are equally severe. A child may have in the 
course of a day a great many mild attacks, but only a few severe ones. 
General convulsions are seen in over one third of the cases, and carpo- 
pedal spasm or tetany complicates a still larger proportion. While this is 
present in the interval, it is always increased during the attacks. 

The duration of the disease varies from a few days to several weeks, or 
even months. In cases which terminate in recovery there is a gradual 
diminution in the frequency and severity of the paroxysms, until they 
finally cease altogether. 

Prognosis. — This is good, except when there are general convulsions. 
The cases in which fatal asphyxia occurs are very rare. Usually with 
proper treatment marked improvement begins in the course of a few 
days. 

Diagnosis. — This is to be made from catarrhal spasm of the larynx. 
The differential points have been mentioned under the latter disease 

4 



CHOREA. 673 

(page 440). Owing to the occurrence of paroxysms and the crowing 
sounds, the disease may be mistaken for whooping-cough, and in fact 
this diagnosis is not infrequently made by parents. A careful examina- 
tion of the patient during the attacks, the absence of cough, and the fre- 
quent association of tetany, are sufficient to differentiate this from per- 
tussis. 

Treatment. — During the attack the object is to break the spasm. In 
mild cases this may be done by sprinkling water in the face. In severe 
cases inhalations of chloroform may be required, and even intubation. 
Between the attacks the patient should be given either bromide and chloral, 
or antipyrine. Sodium bromide, gr. v, and chloral, gr. ij, may be given 
every three or four hours to a child a year old until the frequency and 
severity of the attacks are controlled ; afterward three times a day. My 
recent experience with antipyrine in this disease leads me to the belief 
that it is more effective than bromide and chloral. When the symptoms 
are severe, two grains of antipyrine may be given every four hours to a 
child a year old, the dose being gradually diminished as the symptoms 
improve. 

The general treatment of the child is quite as important as drugs di- 
rected toward relieving the spasm. Cold sponging should be used in 
every case unless it occasions so much fright as to increase the number of 
paroxysms. Careful attention should be given to the diet. Children 
should be kept in the open air as much as possible, and those who are 
rachitic should receive phosphorus. Cod-liver oil is needed in most cases. 
Any source of local irritation, such as enlarged tonsils, elongated uvula, 
or adenoid growths, should be removed ; for, if not the actual cause of the 
attack, they may be the means of aggravating the symptoms. In all cases 
the treatment should be continued for several weeks after the paroxysms 
have subsided. 

CriOREA— SAINT VITUS'S DANCE. 

Chorea is a functional nervous disease characterized by aimless, irregu- 
lar movements of any or all the voluntary muscles. Choreic movements 
are of a somewhat spasmodic character, often accompanied by an apparent 
or real loss of power in the groups of muscles affected, and by a mental 
condition of extreme irritability. 

Etiology. — Chorea is most frequently seen between the ages of seven 
and fourteen years. Of 146 cases, 6 were under five years, 72 between five 
and nine years, and 68 between ten and fourteen years. The youngest 
case of which I have record was that of a child four years old. It is ex- 
tremely rare before the third year, although it may occur even in infancy, 
and in a few recorded cases it was undoubtedly congenital. My own ob- 
servations coincide with those of nearly all writers, that the disease is more 
than twice as frequent in females as in males. While chorea may be seen 
52 



674 DISEASES OF THE NERVOUS SYSTEM. 

at all seasons, it is much more frequent in the spring months. Of 717 
attacks studied by Lewis (Philadelphia), the largest number began in 
March, and the next largest number in May ; in my own cases May stood 
first. 

The relation of chorea to rheumatism is of much importance, and has 
during late years attracted a great deal of attention. Thus far the inves- 
tigations of different writers have given results which are somewhat con- 
tradictory. Some have found evidences of rheumatism in but a small 
proportion of the cases — in not more than 5 or 10 per cent — while the 
statistics of others have placed the percentage of rheumatism as high as 
50 or even 60 per cent. It is rather striking that the statistics of neurolo- 
gists, almost without exception, have given a very much smaller percentage 
of rheumatism in choreic cases than those taken from children's clinics and 
hospitals. The question hinges largely upon what is to be admitted as 
evidence of rheumatism in a child ; if cases of acute articular inflamma- 
tion only, then the number will be very small ; if subacute cases with joint 
swellings are included, the proportion will be considerably larger ; while, 
if we admit cases of acute endocarditis without articular symptoms, and 
those of articular pains and joint stiffness but without swelling, the pro- 
portion will be very much increased. My own belief is that there is a very 
close connection between chorea and the rheumatic diathesis as manifested 
by all the symptoms above noted, and accompanied by a family history of 
rheumatism. On careful scrutiny, the number of cases of chorea in which 
unmistakable evidence of this diathesis is found, is very large, including 
in my own observations over one half the cases. There seems, then, to be 
a large group of cases which may be classed distinctly as rheumatic chorea. 
There are, however, many others in which no such element can be found. 

My associate, Dr. F. M. Crandall, has analyzed 146 cases of chorea 
treated by us at the New York Polyclinic and elsewhere, with the follow- 
ing results : Of 111 cases in which the question of rheumatism was inves- 
tigated there was a definite history of it in 63. In 41, rheumatism occurred 
before the chorea ; in 13, the first evidence of rheumatism was coincident 
with the chorea ; and in 9 it first occurred subsequently to the chorea, usu- 
ally within three months. In about one third of the cases, attacks of rheu- 
matism occurred during or subsequent to the chorea as well as before it. It 
may then be stated that previous rheumatism was evident in 37 per cent, 
concurrent rheumatism in 24 per cent, and subsequent rheumatism in 15 
per cent of the cases. Excluding cases mentioned twice, and also all those 
in which there was a history only of " growing pains," there was evidence 
of articular rheumatism in 56*7 per cent of the cases. Many of these pa- 
tients have been under observation now for several years, and it has been 
interesting to see, as time has passed, how the evidences of the rheumatic 
diathesis have multiplied the longer the cases were followed. 

In the above statistics only articular symptoms have been accepted as 



CHOREA. 675 

evidence of rheumatism. If the cases of endocarditis without articular 
symptoms were included, as I think they might fairly be, it would raise 
the proportion of rheumatic cases still higher. The great proportion 
of cardiac murmurs persisting after chorea, if not all of them, should, I 
believe, be classed as rheumatic, even if no articular symptoms have been 
present. 

Overpressure in school is often an important factor in the production 
of chorea, as has been shown by Sturges (London). Anaemia, if not an 
essential factor, is certainly a very important one, and the great propor- 
tion of cases present very distinct evidences of it. Chorea may develop as 
a sequel of any of the infectious diseases, more particularly scarlet and 
typhoid fevers. It is seen quite often in cases of chronic malarial poi- 
soning. Among the reflex causes may be mentioned phimosis, either 
lumbricoids or pinworms, delayed menstruation, and ocular defects, — 
although the latter more frequently cause a local spasm of the muscles of 
the eyes, which can hardly be considered choreic. It has been claimed 
that chorea may result from the reflex irritation arising from adenoids of 
the pharynx and enlarged tonsils. Whether this is directly or only indi- 
rectly a cause is not evident. The association of the two conditions is not 
very infrequent. 

Hereditary influence is of considerable importance in the production 
of chorea. It is much more frequent in children of neurotic families, and 
very often several successive generations, or several children in the same 
family, may suffer from the disease. 

The exciting cause of chorea in a certain proportion of cases is fright ; 
occasionally it arises from imitation, and the disease has been known to 
occur epidemically in institutions. Choreiform movements may follow 
hemiplegia. Chorea and epilepsy may be associated in the same patient, 
or one disease may follow the other. 

The causes which underlie the occurrence of chorea therefore, seem to 
be a rheumatic diathesis, a neurotic constitution, anaemia, and some severe 
disturbance of general nutrition. When these predisposing factors are 
present, an attack may be induced by many things. The greater the pre- 
disposition the less important may be the exciting cause. A very large 
number of the cases of chorea are in persons who present distinct evi- 
dences of rheumatism, although the explanation of this relationship is net 
yet understood. In another group the neurotic element predominates, and 
in these there may be no connection whatever with rheumatism. 

Pathology. — The exact pathology of chorea is at the present time not 
settled. The seat of the morbid process is undoubtedly the central nerv- 
ous system, probably the motor areas of the cortex. Like epilepsy, 
chorea may follow organic brain disease, especially hemiplegia from cor- 
tical lesions. In some severe cases which were fatal, owing to associa- 
tion with, acute endocarditis, capillary emboli have been found in the 



676 DISEASES OF THE NERVOUS SYSTEM. 

brain. They have, however, often been absent, and probably explain bnt 
a small number of cases, if, indeed, they explain any. The fact that in 
the great majority of the cases of ordinary chorea, complete recovery 
occurs in the course of a few weeks or months, speaks strongly against 
any important structural change in the nervous centres. It seems much 
more in harmony with what we know of the disease clinically, to seek an 
explanation of the symptoms in vascular changes in these parts, having 
their origin in disturbances of nutrition. 

Symptoms. — An attack of chorea generally comes on gradually. At 
first the child, is often considered simply as unusually nervous ; if at school, 
there may be noticed a difficulty in writing, drawing, or in using the 
hands for other delicate operations. At home, the child is continually 
dropping things, has difficulty in feeding himself, sometimes in buttoning 
his clothes, and very frequently he is not brought to the physician until 
the symptoms have lasted a week or two. Sometimes the legs are first 
affected, and a history is given of frequent falls, a stumbling gait, diffi- 
culty in going upstairs, etc. At other times the spasm is first seen in the 
facial muscles, with disturbance of articulation, twitchings of the eye 
muscles, and the child may be punished for making grimaces. In most 
cases the spasmodic movements soon extend to all parts of the body. 
According to Starr, they remain limited to one side of the body (hemi- 
chorea) in about one third of the cases. When fully developed, the move- 
ments of chorea are quite unmistakable. They are irregular, jerking, 
spasmodic, never rhythmical, rarely symmetrical, and vary in intensity 
from an occasional muscular contraction to almost constant motion. The 
movements are not under the control of the patient's will, and are usually 
intensified by efforts to suppress them. They are increased by excitement, 
embarrassment, or fatigue, but do not as a rule continue in sleep. 

Very often there is some weakness of the affected muscles, which may 
be so great as to lead to the suspicion that actual paralysis exists. Not in- 
frequently I have had patients brought to the clinic for supposed paralysis, 
either of one extremity or of one side of the body, where the choreic move- 
ments have not been severe enough to attract the attention of the mother. 
This paralysis usually disappears in the course of a few weeks. 

In severe forms of chorea the patient may be unable to help himself 
or even to walk, from the inability to co-ordinate muscular movements. 
The symptoms may be so intense as even to endanger life. Such cases, 
however, are dangerous, not from the choreic movements, but from the 
acute endocarditis with which they are frequently associated. 

The mental condition of choreic patients is one of marked irritability. 
They are fretful, emotional, easily provoked to tears or laughter, and 
often very difficult to control. In extreme cases a mental disturbance 
bordering upon acute mania has been observed. All degrees of speech 
disturbances may be met with, from the slight difficulty in articulation 



CHOREA. 677 

due to inability properly to control the movements of the tongue and lips, 
to a condition in which speech is almost impossible. In rare cases speech 
has been temporarily lost. Heart murmurs are frequent in chorea. Some 
of these are of anaemic origin, some possibly are due to chorea of the heart- 
muscle itself — although this is a matter of some uncertainty — but a large 
number, probably the majority, are due to concurrent endocarditis, as is 
shown by the fact that they are permanent, and are followed by all the 
signs of organic heart disease. During every attack the heart should be 
closely watched, especially in children in whom there is a strong predis- 
position to rheumatism. 

The urine in chorea has recently been studied with care by Herter and 
Smith, who have shown that in very many cases there is an excessive 
elimination of uric acid. This is neither the cause nor the effect of the 
chorea, but is to be regarded as evidence of a profound disturbance of 
nutrition, of which the choreic movements are but another manifestation.* 
The general condition of choreic patients is usually much below normal. 
They are anaemic ; the appetite is poor, often capricious ; they sleep very 
badly ; they suffer frequently from headaches ; they are easily fatigued by 
slight muscular exertion ; and in short they have all the symptoms of a 
greatly disturbed nutrition. 

Course and Duration. — The ordinary form of chorea tends to spon- 
taneous recovery in from six to ten weeks. Exceptionally it may last for 
three or four months. In a small number of cases the disease may be- 
come chronic and continue indefinitely. Certain forms of local spasm, 
particularly choreiform movements of the muscles of the face, eyes, or 
neck, may be permanent. In any case of chorea which lasts longer than 
the usual time, the patient should be carefully examined for some cause of 
peripheral irritation. The tendency to relapses and second attacks is very 
marked. Later attacks are likely to occur in the spring succeeding the 
first illness, and in a small number of patients attacks may come every 
year for four or five years. 

Diagnosis. — There is little difficulty in recognising chorea from the 
sudden, irregular, spasmodic contraction of the muscles coming on under 
the circumstances indicated. No other movements of childhood are 
likely to be confounded with it. The form of chorea following hemi- 
plegia is usually more athetoid than choreic, yet at times it closely simu- 
lates ordinary chorea. The difficulty in distinguishing between the two is 
often increased by the fact that the weakness of simple chorea may, if uni- 
lateral, closely simulate hemiplegia. The existence of rigidity, contractions. 



* Dr. Herter has called my attention to the fact that in many cases <»f well-marked 
chorea the urine contains a peculiar reddish colouring matter called hsamato-porphyrin. 
This is also found in many cases of rheumatism, another evidence of the close relation- 
ship existing between these two diseases. 



67S DISEASES OF THE NERVOUS SYSTEM. 

and increased reflexes belong exclusively to hemiplegic cases, and these will 
usually suffice to clear up all doubt with reference to the diagnosis. 

Prognosis. — As a rule this is favourable, and complete recovery can be 
predicted, the exceptions to this being few in number. Parents should 
always be warned of the tendency of the disease to return in succeeding 
years, and the fact should be stated that in a certain proportion of cases 
the disease may be permanent. The prognosis of the cardiac murmurs 
occurring in chorea should always be guarded, although some of these are 
functional and disappear with recovery from the chorea ; but the number 
of those which do not disappear is sufficiently large to make one always 
apprehensive as to the ultimate result. Acute chorea accompanied with 
endocarditis may be fatal ; a number of such cases are on record in which 
there has been no other evidence of rheumatism. 

Treatment. — The general management of the case is equally impor- 
tant with the administration of drugs. A child with chorea should at 
once be taken from school, and should never be subjected to punishment 
or to ridicule on account of the movements. Special attention should 
be given to the patient's diet and general nutrition. Tonics, especially 
ironware indicated in most cases. The food should be simple and nutri- 
tious, and all stimulants, particularly tea and coffee, should be absolutely 
prohibited. While fresh air is desirable, exercise should be prescribed 
with great caution and its effect should be carefully watched. It should 
nevei be carried beyond the point of slight fatigue. A certain amount of 
moral restraint is absolutely necessary ; thus it often happens that choreic 
patients do very badly at home where they are indulged and receive sym- 
pathy, while in a hospital, where they are under restraint and made to con- 
trol themselves, they begin to improve immediately. Gymnastics, although 
useful in some of the milder cases, may do positive harm in those which 
are severe. They should be regularly and systematically practised twice 
a day, but not continued too long. In all severe cases the " rest treat- 
ment " should be employed, and equal benefit is also seen in the milder 
ones, — the patient is put to bed, and complete mental and physical rest 
secured. This may be combined with gentle massage for fifteen or twenty 
minutes a day. The daily use of warm baths, either alone or in conjunc- 
tion with massage, is decidedly beneficial. In other cases the regular use 
of cold sponging is of the greatest value. 

With reference to the use of drugs, it is advisable to separate from 
other cases those in which the connection with rheumatism is very close. 
In the rheumatic cases, salicylate of soda is often efficient, while the drugs 
usually employed may be absolutely without effect. In a case recently 
under observation, arsenic had been continued for two weeks without the 
slightest improvement, when the patient had an intercurrent attack of 
subacute rheumatism for which salicylate of soda in full doses was given, 
with the effect of controlling the choreic symptoms promptly and perma- 



HABIT SPASM. 679 

nently. In the non-rheumatic cases, arsenic is almost universally admitted 
to be the most valuable remedy we possess. The method of administra- 
tion is important ; failure most frequently results from the use of too small 
doses. Beginning with four drops of Fowler's solution three times a day 
for a child of eight . years, the daily quantity may be increased by two 
drops each day until a disturbance of the stomach or bowels is produced, 
with puffiness under the eyes. The drug should now be stopped for two or 
three days, and then the same doses resumed and gradually increased, 
usually up to twelve drops three times a day, sometimes to fifteen, and 
even twenty drops, unless the movements cease before that time; but 
when this occurs the drug should be stopped. Arsenic should always be 
given after meals, and largely diluted, the dose being taken in a full glass 
of water, but not necessarily drunk at one time. The possibility of arsenical 
poisoning should be remembered, although it is extremely rare. Semple 
has reported a case in which multiple neuritis and general pigmentation 
of the skin occurred after four weeks' administration of the drug. 

In the event of the failure of arsenic alone, it should be combined with 
the rest treatment. Drugs which sometimes succeed where arsenic fails 
are antipyrine and strychnine. From twenty to thirty grains of antipyrine 
should be given daily in divided doses to a child of eight years. There 
are a certain number of cases in which striking improvement follows the 
use of this drug if given in the full doses mentioned. To a child of eight 
years strychnine should be given in doses of ^ of a grain three times a 
day, the dose being gradually increased until double this quantity is 
given ; sometimes even larger doses than these are well borne. Galvanism 
is of some value in cases not relieved by drugs. Acute chorea of great 
severity may require opium, bromide and chloral, or even chloroform. 

In estimating the value of drugs in the treatment of chorea, the natu- 
ral course of the disease should be kept in mind, since those drugs which 
are taken after the third or fourth week are much more likely to be 
thought beneficial than those used in the early period of the attack. 

There is no doubt that chorea may be dependent upon some ocular 
defect, and a correction of this will then form an essential part of the 
treatment, although few, if any, cases are cured by attention to the eyes 
alone. 

Chorea has a strong tendency to recur, especially in the spring of the 
year. Children who have had one attack should be closely watched, par- 
ticularly with reference to their work in school. They should not be 
crowded in their studies, they should have long vacations, and the nervous 
system should not be put upon any severe tension for a long time. 

OTHER SPASMODIC AFFECTIONS. 

Habit Spasm. — This term was, I think, first suggested by Gowers, to 
describe certain muscular movements of a spasmodic character which at 



080 DISEASES OF THE NERVOUS SYSTEM. 

first are only occasionally noticed, but which sometimes persist until they 
become habitual and almost entirely involuntary. The condition was pre- 
viously called " habit chorea " by Weir Mitchell. The movements usually 
affect the muscles of the face, but they may be seen in almost any part of 
the body. The most frequent varieties consist of blinking or sudden 
frowning, raising the eyebrows, or some peculiar grimace. At other times 
there is sudden twisting of the head, shrugging of the shoulders, or jerk- 
ing of the hands. It is not often seen in the leg, but the muscles of 
respiration are quite frequently affected. There may be a half-sigh, a 
sort of sob, or a peculiar dry, laryngeal cough. 

These movements are at first only occasional ; but as the habit becomes 
more firmly fixed the spasm recurs every few minutes, and in severe cases 
it may be almost continuous. In nearly all cases it increases by observa- 
tion. The same form of spasm does not always continue, but after a time 
one may subside and another take its place. The condition may last for 
months or years, and it may even be permanent. 

The causes are those of neuroses in general. In the beginning, at 
least, there is usually a somewhat depreciated general health. The patients 
are nervous children of neurotic antecedents. There may be a history of 
some definite exciting cause, such as illness or overwork in school. The 
spasm of the muscles about the eyes may be associated with pathological 
conditions of these organs. This may be enough to start the spasm, if not 
to continue it. Both sexes are affected. In boys, masturbation may some- 
times be an exciting cause. 

Habit spasm is to be differentiated from chorea : this is usually easy, 
from the limitation of the movements to one part or group of muscles and 
from the duration of the disease. 

Treatment is quite unsatisfactory after the habit has become fixed, 
hence it is of the utmost importance that it should be arrested at the 
earliest possible age. Punishments are of no avail, and usually aggravate 
the condition. Rewards are much more effectual. The general health 
should receive attention and nerve tonics should be given, especially 
strychnine. 

Athetosis and Athetoid Movements. — This term, introduced by Ham- 
mond, is used to describe a chronic form of spasm usually seen in the 
hand, but sometimes also in the foot, and even the face. It may affect 
both sides, but in most cases it is unilateral. The movement is slow, 
irregular, and inco-ordinate — a sort of " mobile spasm," as it has been 
called — and there may be associated a certain amount of muscular rigidity. 
Such movements may occur in persons otherwise healthy, but are usually 
seen as a sequel of cerebral palsies, generally hemiplegia. Recovery from 
the hemiplegia may be so nearly complete that the athetoid movements 
are looked upon as primary. In some cases the movements are more 
rapid and somewhat resemble those of chorea, — a condition which 



NYSTAGMUS. 681 

is sometimes classed as post-hemiplegic chorea. Athetosis is not influenced 
by treatment. 

Rotary and Nodding Spasm of the Head. — These are rare forms of 
irregular movements usually observed in infancy. The condition was 
described long ago by Henoch, and since then cases have been reported by 
Hadden,* Peterson, and others. The most frequent is the rotary spasm, 
which consists in a side-to-side oscillation of the head, which may be slow 
or rapid, and in some cases is almost continuous. Some children have at 
times the nodding spasm also, and in others this is the only movement 
seen. Nystagmus is frequently associated, and may be of one or both sides. 
In a few of the reported cases convergent strabismus was present. 

The causes of the condition are extremely obscure. It is usually seen 
in infancy between the third and eighteenth months, and, like most nervous 
symptoms of this period, has been ascribed to dentition, but without any 
special reason. In three of the cases reported by Hadden, it followed an 
injury to the head, and might perhaps be regarded as a result of cerebral 
concussion. 

As a rule, the condition lasts for several months and improves, — in fact, 
recovery generally occurs. The prognosis is then usually favourable. In 
most of the reported cases improvement has followed the use of bromides ; 
from ten to twelve grains daily should be given. 

Nystagmus. — This term is applied to rhythmical, involuntary, oscillatory 
movements usually of both eyes. They are caused by the alternate con- 
traction of opposing muscles. Nystagmus may be either vertical or hori- 
zontal. It is most often seen in infants a few months old, and is a 
symptom of irritation which may be general or local. In some cases the 
movement is almost continuous, occurring even in sleep ; in others, it is 
only noticed at times of special excitement. 

The etiology of nystagmus is obscure, and, it may occur in quite a 
variety of conditions, — sometimes referable to the eye, at other times to 
the central nervous system. On the part of the eye, nystagmus may be 
due to blindness from any cause, to congenital cataract, corneal opacity, 
disease of the choroid or retina, or to errors of refraction. It may be 
seen in almost any organic disease of the nervous system, both with focal 
and diffuse lesions, especially in chronic hydrocephalus, insular sclerosis, 
tuberculous meningitis, and in diseases in which sight is impaired. Nystag- 
mus may be of reflex origin, as in a case recently occurring in the Babies' 
Hospital, where an infant with a severe diarrhoea had repeated attacks, 
which disappeared each time after intestinal irrigation. While it is of no 
importance as a localizing symptom, nystagmus usually indicates some- 
thing more than functional disturbance. An exception to this may per- 
haps be made when it follows cerebral concussion. In such cases it is 



* Lancet, June 14, 1890. 



682 DISEASES OP THE NERVOUS SYSTEM. 

usually temporary, disappearing in a few days or weeks. Under most 
other conditions it may continue indefinitely. 

The condition of the eyes should be investigated in every case of 
nystagmus ; it is only when the cause is here, and can be removed, that 
habitual nystagmus is amenable to treatment. 

Hiccough. (Singultus). — This is a spasm of the diaphragm which is 
usually seen in young infants. In them it is in most cases due to some 
irritation in the stomach. It is seen after eating, and may depend upon 
overfilling of the stomach by food, swallowing of air, etc. In other 
cases it has no relation to the taking of food, and is to be regarded as 
a form of reflex spasm, which may occur from a variety of causes, such as 
cold feet, chilling of the surface during bath, or suddenly taking an in- 
fant from a warm bed into a cold room. In cases like the above, hic- 
cough, though sometimes annoying, is of little importance. It may be 
associated with gastric indigestion, with intestinal flatulence or inflamma- 
tion, with peritonitis or intestinal obstruction. With the last two condi- 
tions it is always an unfavourable symptom. In older children hiccough 
sometimes occurs as a pure neurosis. 

The object of treatment is to remove the cause. In infants this is to 
aid in the expulsion of the gas from the stomach by manipulation, position, 
or the other means useful in gastric colic. Where it is a nervous symptom 
only, it may be arrested by holding the breath, prolonged forced ex- 
piration, as in blowing a trumpet, and sometimes may require the use 
of such drugs as control muscular spasm — e. g., antipyrine or chloral. 

Thomsen's Disease (Congenital Myotonia). — This rare disease is usually 
congenital. It may occur in several members of the same family, and is 
often hereditary. The characteristic symptoms are a peculiar rigidity of 
the muscles which is observed when they are first brought into action after 
repose. This rigidity is spasmodic, and usually continues but a few 
moments. It may recur when voluntary movements are again attempted. 
If, however, muscular effort is persisted in, it soon passes off. It is in- 
creased by apprehension, excitement, or cold, and by observation. The 
legs are most frequently affected, the condition being often noticed when 
the patient starts to walk ; any of the voluntary muscles, however, may 
be involved. It may be greater upon one side of the body than upon the 
other. The muscles are abnormally sensitive to mechanical stimulation, 
and often to galvanism. They are above normal size, and the fibres them 
selves are enlarged. 

The pathology of this disease is, according to Growers, an altered func- 
tional condition of the muscle fibres, and an abnormal functional state of 
the nerve cells of the cord and the cortex. It is incurable, although the 
symptoms may be improved by active muscular exercise. 

Cervical Opisthotonus. — This is usually a symptom of disease at the 
base of the brain, occurring with simple, tuberculous, and chronic basilar 



TORTICOLLIS. 



683 



meningitis, sometimes with tumours of the posterior fossa of the skull. 
However, in certain cases it occurs as a form of reflex spasm, particu- 
larly in young infants who are suffering from diarrhoeal diseases or maras- 
mus. In these cases it may last for days or weeks. The deformity is 
produced by a contraction of the superior fibres of the trapezius and by the 
posterior group of cervical muscles. 

Torticollis — Wry-Neck. — Torticollis is usually produced by a tonic 
spasm of one sterno-mastoid muscle, with which may be associated spasm 
of the posterior cervical muscles, 
including the trapezius. In re- 
cent cases there is simply a con- 
dition of muscular spasm ; in those 
of long standing there may be 
permanent shortening of the af- 
fected muscle, atrophy, and par- 
tial paralysis. A somewhat simi- 
lar deformity may be caused by 
cicatricial contraction of the tis- 
sues of the neck following burns. 

The deformity varies some- 
what according as the sterno-mas- 
toid muscle is alone affected, or 
the posterior muscles also, and as 
to which predominates. In sim- 
ple sterno-mastoid spasm the head 
is inclined to the affected side and 
rotated toward the opposite side ; 
the chin is raised, and the ear 
approaches the clavicle. When 
other muscles are . involved the 

deformity is modified. If the trapezius is affected (Fig. 109) there is less 
rotation of the head, but it is drawn to the affected side and somewhat 
backward, while the shoulder is raised and the spine curved. Both of 
these symptoms may be seen to a slight degree in almost any marked case 
of sterno-mastoid spasm. Sometimes the spasm of the posterior muscles 
affects both sides ; the head is then drawn backward and held rigidly but 
without rotation. In most of the recent cases the deformity can be 
partially or entirely overcome by passive force; but after a time this is 
impossible, owing to muscular shortening. In recent cases also localized 
pain and tenderness are frequently present, and sometimes they are severe. 

Etiologij.— Spasmodic torticollis may be produced by anything causing 
irritation of the trunk or the branches of the spinal accessory nerve ; the 
source may be in the spinal canal, in the cranium, along the course of the 
nerve trunk, or of any of its peripheral fibres. 




Fig. 109.— Spasmodic torticollis from malaria. 
Trapezius and sterno-mastoid of the left 
side are affected. 



684 DISEASES OF THE NERVOUS SYSTEM. 



Cases are usually divided into congenital and acquired. Whitman,* 
from the records of the Hospital for the Euptured and Crippled, New 
York, for nineteen years, gives the following statistics of 264 cases, — torti- 
collis from Pott's disease not being included : Males, 109 ; females, 155 ; 
congenital, 32 ; under two years, 33 ; from two to ten years, 153 ; over 
ten years, 46 ; acute (i. e., of less than two months' duration), 77 ; chronic, 
60, of which number 22 had lasted two years or longer. 

Regarding the cause of congenital torticollis there is some dispute. 
Such cases have often been attributed to the contraction resulting from 
hematoma of the sterno- mastoid (page 94). My own experience coin- 
cides with Whitman's, that this is rarely if ever the case. While it is pos- 
sible that the deformity is sometimes the consequence of injury received 
during delivery, the cause of most of the congenital cases goes back to con- 
ditions existing before birth. It may be compared to club-foot, and 
maybe due to a faulty position of the child in utero, or it may come 
from more serious conditions, such as malformations, or unequal develop- 
ment of the two sides of the body. 

One of the most frequent causes in the acquired cases, is irritation of 
the spinal accessory nerve by an enlarged cervical lymph gland ; this was 
the cause assigned in nearly half of Whitman's cases ; such is the usual 
etiology of torticollis following scarlet fever, measles, or diphtheria. I 
have seen it in the early stage of quinsy, and it may occur in cellulitis of the 
neck. A cause which the physician should always have in mind is cervical 
Pott's disease ; torticollis may be the earliest, and for several weeks some- 
times almost the only, objective symptom of this disease. Torticollis 
coming on acutely is most frequently due to cold (rheumatism?) or 
malaria. I have notes of eight cases clearly traceable to malaria, and have 
seen at least a dozen others. In several of these there was a distinct perio- 
dicity in the spasm, it recurring regularly at about the same time each 
day until quinine was given ; in some cases it was accompanied by fever, 
in others not. In the so-called rheumatic torticollis, muscular pain and 
soreness are rather more prominent than in the other forms. In fourteen 
of Whitman's cases the spasm was attributed to injuries other than burns ; 
and in only nine was it associated with some other disease of the nervous 
system, most frequently with chorea. 

Prognosis. — The result in a case of torticollis depends upon the cause, 
the severity, and the duration of the deformity. Most of the acute cases 
from malaria, rheumatism, etc., recover, under appropriate treatment, in 
the course of a few weeks, sometimes in a few days, and not a few re- 
cover spontaneously. The congenital cases with slight deformity are 
usually amenable to mechanical or postural treatment if begun early. 
There is, however, in most of the other varieties a disposition of the de- 

* Observations upon Torticollis, Medical News, October 24, 1891. 



HYSTERIA. 685 

formity, if untreated, to persist, and even to increase. If it has lasted 
several months the probabilities of spontaneous recovery or even of im- 
provement are small. 

Treatment. — The first indication is to remove or treat the cause where 
one can be found. Malarial cases require quinine ; rheumatic cases are 
benefited by rest in bed, hot applications, counter-irritation, friction, and 
sometimes by anti-rheumatic remedies. Cases which have lasted a month 
usually require some orthopaedic head-support, and those which have 
lasted six months or more are rarely cured without a surgical operation. 
This may be either a subcutaneous tenotomy or myotomy of the sterno- 
mastoid, or an open incision. Whitman gives the result of thirty-two cases 
admitted for treatment to the hospital mentioned, as follows : In 17 in 
which the deformity had lasted less than six months, 10 were cured, the 
average duration of treatment being three months; 4 w r ere improved, and 
3 not improved, the average duration of treatment in these cases being 
eleven months. Of 15 cases in which the deformity had lasted over six 
months, none were cured and only 6 improved, after an average of about 
eight months' treatment. In the foregoing series of cases the treatment 
consisted mainly in the use of orthopaedic apparatus ; later results from 
incision have been considerably more favourable. But these figures show 
how serious a matter is an old case of torticollis, and emphasize the im- 
portance of resorting to efficient measures early in the disease. 

HYSTERIA. 

This is not a disease of childhood, but one which is occasionally seen 
in early life. All that will be attempted in this chapter is to point out the 
most common manifestations of hysteria when it occurs in young children. 
After puberty it is essentially the same as in adults.* 

Etiology. — Hysteria is very rare before the seventh or eighth year, and 
most of the cases seen in children occur after the tenth year. As to sex, 
there is no such predominance of females as in later life, although even in 
childhood they are more frequently affected than males. Hereditary 
influences play an important part in the production of this disease. It is 
seen in children who inherit a nervous constitution, or in whose parents 
nervous diseases, such as insanity, hysteria, or alcoholism have been 
present. Of the other etiological factors the most important are a dis- 
ordered nutrition, frequently with anaemia or chlorosis, and overpressure 
in schools. Masturbation or phimosis may act as an exciting cause, or, 
indeed, anything which leads to an exalted nervous irritability and depre- 
ciation of the general health. It is occasionally associated with tuber- 

* For a fuller discussion of this subject, and references to recent literature, see 
Mills, in Keating' s Cyclopaedia, vol. iv. 



686 DISEASES OP THE NERVOUS SYSTEM. 

culosis; it may follow any of the acute infectious diseases; or it may be 
excited by injury, fright, or imitation. 

Symptoms. — There is scarcely any disease in which the clinical picture 
presented is so varied as in hysteria. It may simulate almost any form of 
organic disease of the brain, lungs, digestive organs, bones, or joints. The 
most common symptoms may be grouped under four general heads. These 
are, however, seen in almost every conceivable combination. 

1 . Psychical symptoms. — Where these predominate there may be seen 
periods of mental depression of longer or shorter duration, a change in 
disposition, an indifference to surroundings, a capricious humour, or a nerv- 
ous condition of extreme irritability with irregular paroxysms of laugh- 
ter or weeping without cause. There may be great excitability of temper, 
and fits of passion almost maniacal in their severity. There may be vari- 
ous hallucinations. Sleep is frequently disturbed, sometimes by attacks 
resembling ordinary night-terrors ; sometimes somnambulism .is present. 
There is often a disposition to deception about the most trivial matters, 
which may last for weeks. There is a tendency to imitate the symptoms 
of various diseases, which the patients may have witnessed in others or 
about which they have read. 

2. Sensory symptoms. — These are the most frequent manifestations of 
hysteria in early life. There is often general or local hyperesthesia, 
which may be so great as to simulate inflammation of the various internal 
organs. Anaesthesia is much less common, although it may be seen in 
children as young as eight or nine. Headache is an occasional symptom, 
and is sometimes associated with great tenderness of the scalp. There 
may be neuralgias in the different parts of the body, or sharp epigastric 
pain, sometimes accompanied by vomiting. Sometimes the special senses 
are affected, giving rise to hysterical blindness or deafness, usually of short 
duration. 

3. Joint symptoms. — These are really a variety of sensory disturbances. 
They are not uncommon, and are often most puzzling. The symptoms 
may be referable to the spine, or to any of the large joints, particularly 
those of the lower extremity. All forms of organic disease of these joints 
may be simulated, and these patients are often treated for months with 
orthopaedic apparatus, with the belief that they are suffering from Pott's 
disease, lateral curvature of the spine, club-foot, or ostitis of the hip, knee, 
or ankle. Oases of this sort have been very fully described by G-ibney,* 
and by Shaffer, whose articles should be consulted for fuller details. They 
are usually seen between the ages of ten and fourteen years, and occur in 
both sexes. There may be lameness referred to one of the large joints, 
curvature of the spine, or torticollis. The symptoms are most frequently 

* Gibney, Transactions of the American Neurological Association. 1877. Shaffer, 
Archives of Medicine, New York, December, 1879, February and April, 1880. 



HYSTERIA. 687 

referred to the hip, and next to the knee, the ankle, or the spine. The 
pain is often acute. It is increased by motion, and by attempts at over- 
coming the deformity, if any is present. There is a marked hyperesthesia 
of the whole limb, and sometimes of the body. In nearly every case there 
is marked tenderness of the spine upon pressure, especially in the dorsal 
region. The deformity may be very slight from spasm of the flexors 
only, or it may be severe, and followed by contracture, so that the thighs 
may be flexed tightly against the abdomen with the heels against the 
buttocks. Such deformities may last for months. There may be con- 
siderable muscular atrophy, but only that which comes from disuse. A 
special difficulty in diagnosis arises from the circumstance that these 
symptoms occasionally follow an injury. 

Organic disease of bones and joints may usually be excluded by atten- 
tion to the following points : The mode of onset is more abrupt than is 
seen in bone disease, and the course of the disease is quite irregular. The 
degree of deformity is greater than is seen in bone disease of the same 
duration. There are general hyperesthesia of the limb, acute tenderness of 
the spine upon pressure, and undue sensitiveness to heat or cold. The de- 
formity varies from time to time, being always more marked when examina- 
tion is attempted. If the patients are closely watched, other evidences of 
hysteria may be seen. Under complete anesthesia the contractures may 
disappear entirely. There is no enlargement of the articular ends of the 
bones, no swelling of the soft parts, and no evidence of active inflammation 
or of suppuration. All the symptoms except the deformity are subjective. 
Under proper treatment there is in most cases perfect recovery, often in a 
surprisingly short time. 

4. Motor and convulsive symptoms. — In the milder forms we may 
see many varieties of tonic or clonic spasm. There may be seen local 
spasm of the eyes, face, or mouth, spasm of the muscles of the neck pro- 
ducing torticollis, of the muscles of respiration causing dyspnoea, which 
may be constant or paroxysmal. There may.be hiccough, or spasm of the 
larynx causing hysterical aphonia. A very common symptom is hysterical 
cough, which may be* so frequent and so severe— even accompanied by 
hemoptysis — that grave disease of the lungs is suspected ; the chest, 
however, is free from the physical signs of disease. There may be fre- 
quent attacks of vomiting with eructations; these maybe continued some- 
times even for months, and in rare instances blood has been vomited. 
There may be dysphagia from spasm of the oesophagus, or regurgitation 
of food on attempts at swallowing. In more severe cases we may have the 
symptoms of chorea major and attacks of hystero-epilepsy. The latter are 
rare in children and do not differ essentially from such attacks in older 
patients. There are usually prodromal symptoms. The convulsive move- 
ments are exceedingly varied in type. There are painful sensations and 
sensitive areas, by pressure upon which hysterical symptoms may be in- 



flg8 DISEASES OF THE NERVOUS SYSTEM. 

creased or even convulsions excited. The respiration may be rapid or 
irregular. All variations in tonic and clonic spasm may be seen. Opis- 
thotonus is frequent. Consciousness is not fully lost, but is disturbed, and 
hallucinations are present. The temperature is normal. 

Hysterical paralysis is not common in children, but it may be seen 
even in the very young. Gillette has reported the case of a child eighteen 
months old who exhibited the symptoms of hysterical palsy of one arm. 
Other symptoms occasionally seen in hysteria, are persistent anorexia, poly- 
uria, sometimes incontinence of urine, disturbance of the secretion of 
saliva or perspiration, and very rarely hysterical fever. 

The general condition of hysterical patients is usually below the nor- 
mal. They are poorly nourished and anaemic ; they sleep badly ; they have 
capricious appetites, feeble digestion, and faulty assimilation. 

Diagnosis. — Hysteria is apt to be overlooked because its occurrence in 
children is not considered as often as it should be. In most cases the 
diagnosis is easy if hysteria is suspected. A combination of vague discon- 
nected symptoms is usually present which admits of no other explanation. 
Organic disease can be excluded only by careful aud repeated examinations. 
It is to be borne in mind, however, that hysteria not infrequently compli- 
cates organic or constitutional disease. Much importance is to be attached 
to a family history of hysteria or of other neuroses. From poliomyelitis, 
hysterical paralysis is differentiated by the presence of faradic contractility 
even though atrophy exists. Hysterical convulsions are differentiated from 
true epilepsy by the absence of any elevation of temperature, of biting of 
the tongue, evacuation of the viscera, of a violent fall, and often by the 
rapid disappearance of the symptoms under appropriate treatment. 

Prognosis. — This is better than in adults, especially if the cases are 
taken in hand early, before the disease has become deeply seated. Very 
much depends upon how well the directions for treatment can be carried 
out. The prognosis is less favourable where the hereditary tendency is 
strongly marked. In many cases there are relapses later in life. 

Treatment. — Prophylaxis is of much importance. When a tendency 
to hereditary nervous diseases exists in a family, or. whenever very nervous 
children are placed under the physician's care, every means should be taken 
toward muscular development, keeping the nervous system in the back- 
ground. Such children should lead an out-of-door life as much as possi- 
ble, preferably in the country ; they should keep early hours, have regular 
exercise, and their education should be directed with moderation and judg- 
ment ; special attention being paid to regularity of work, and the preven- 
tion of overpressure in schools. Theatres and exciting books should be 
avoided. All stimulants, including tea and coffee, should be absolutely 
forbidden. The diet should be plain and nutritious. It is highly impor- 
tant that such children should be removed from association with a hysteri- 
cal mother, when this is possible. 



HEADACHES. 689 

In the general management of a case of hysteria, it is of the first im- 
portance that the child should be cared for by a person of firmness, who 
can exercise proper control. Hysterical children are always managed 
more easily when they are removed from their homes and placed under the 
charge of a good trained-nurse. Isolation is absolutely essential in many 
cases. The general health should be carefully looked after, and arsenic, 
iron, cod-liver oil, and other tonics given according to indications. Horse- 
back exercise and other out-of-door sports should be encouraged, and every 
means taken to interest the child in something which requires physical 
exercise. In cases of simulated disease, the child should be put to bed, no 
books or toys allowed, and no effort made toward his amusement. Xo 
sympathy should be exhibited, but the child treated with kindness and 
firmness. This moral treatment is quite as important as any other part 
of the therapeutics. In cases with hysterical joint symptoms the most 
valuable thing is counter-irritation to the spine, preferably by the Paque- 
lin cautery. Some cases are benefitted by galvanism. The moral effect 
of hypodermics, even of cold water, is sometimes striking. Under no cir- 
cumstances should mechanical force be used to overcome deformity. Many 
cases of hysteria improve under hydrotherapy ; the cold douche, the cold 
pack, or the shower bath may be used. This is valuable in conjunction 
with massage and the "rest treatment." 

In attacks of hystero-epilepsy the cold douche may be used, or pressure 
made upon the testicle or ovary. In severe cases ether may be given. In 
all hysterical cases the condition of the bowels should receive careful atten- 
tion, as these patients are very prone to obstinate constipation. 



HEADACHES. 

Headaches are not common in little children except in connection 
with disease of the brain or meninges ; in older children they occur from 
causes similar to those seen in adult life. The most frequent headaches 
may be grouped in the following classes : 

1. Toxic headaches. — Such are the headaches resulting from uraemia, 
from carbonic acid in poorly ventilated rooms, and from malaria. But 
the largest number are due to absorption of toxines from the intestines, 
and are associated with chronic indigestion and constipation. 

2. Headaches from anwmia and malnutrition. — These are most fre- 
quently seen in girls from ten to fourteen years old. Some are intellec- 
tually bright, and have been crowded in their school work ; others are dull 
and learn only with difficulty, and in consequence worry over their work 
until their health becomes undermined. They sleep badly, lose appetite, 
and often become choreic. The anaemia maybe either the cause or the 
result of these symptoms. The urine in these cases often contains a large 
excess of uric acid. 

53 



090 DISEASES OF THE NERVOUS SYSTEM. 

3. Headaches of nervous origin. — These may occur in children who 
are highly neurotic, either from their inheritance or surroundings, and in 
those who are the subjects of epilepsy or hysteria, and they may be symp- 
tomatic of organic disease of the brain, such as tumour or tuberculous or 
syphilitic meningitis. True facial neuralgia is rare in childhood except 
from carious teeth ; from this cause, however, it is not infrequent. 

4. Headaches due to disease of some of the organs of special sense. — In 
connection with the eyes there may be conjunctivitis, keratitis, iritis, errors 
of refraction, or strabismus ; connected with the nose there may be polypi, 
hypertrophic rhinitis, or adenoid vegetations of the pharynx ; connected 
with the ears there may be otitis or foreign bodies in the canal. Each one 
of these conditions requires special treatment. 

5. Headaches due to inherited gout or rheumatism. — These are not 
very frequent, but they may be severe, and may at times simulate the onset 
of meningitis. They are often accompanied by pains in the joints, mus- 
cles, or nerve trunks ; they may be associated with a urine which is highly 
acid and contains deposits of oxalates or of free uric acid. 

6. Disturbances of the genital tract are rarely a cause of headaches in 
children, although this may be the case in girls about the time of puberty, 
especially where menstruation is delayed or difficult. 

Diagnosis. — The diagnosis of headaches includes the discovery of the 
cause, and this is often difficult. In an infant or a young child, organic 
disease of the nervous system should always be suspected as a cause of se- 
vere headaches. In older children the important things to be considered, 
because the most frequent, are digestive disturbances, nervous exhaustion, 
malnutrition, and visual disorders. An absolute diagnosis in a case of 
persistent headache can be made only by a careful physical examination, 
not omitting a study of the urine ; often there must be a close observation 
of the patient for some time. 

Treatment. — The only successful treatment is that which is directed 
toward a removal of the cause. Each one of the different groups above 
mentioned is to be managed differently, according to the principles else- 
where laid down regarding the treatment of these conditions. For the 
relief of the symptom, cold to the head, a hot foot-bath, and phenacetine 
in moderate doses are perhaps the most certain of all remedies. 

DISORDERS OP SPEECH. 

In this chapter will be discussed only functional speech defects,* 
those depending upon organic conditions being considered in connection 
with diseases of the brain. The most common varieties are stuttering, 
stammering, lisping, alalia, backwardness, and functional aphasia. All 

* See Wyllie, Edinburgh Medical Journal, October, 1891. 



DISORDERS OF SPEECH. 691 

forms are much more frequent in boys than in girls, the proportion being 
more than four to one. 

Stuttering. — This is the most common form of speech disturbance. 
Articulation is distinct and the separate sounds are properly produced, 
but there is a difficulty in connecting the consonant with the succeeding 
vowel ; this seems like an obstacle to be overcome. Stuttering is occa- 
sionally seen in most children. It is more frequent in the third and 
fourth years, before speech is thoroughly mastered. At this age it is 
aggravated or produced by disturbances of nutrition, but is usually of 
temporary duration, lasting for a few weeks or months. Only recently a 
little boy of four was under my care, who became very anaemic, slept 
poorly, and suffered from malnutrition as a result of the confinement inci- 
dent to a home in the city. He soon began to stutter, and in a short 
time it became painfully marked. After a few weeks in the country he 
improved very much in his general condition, gained four or five pounds 
in weight, and his stuttering completely, and I think permanently, disap- 
peared. Such disturbances as this are analogous to chorea. In other cases 
stuttering follows some acute illness, and under such conditions also it is 
usually of short duration. 

Most children who become habitual stutterers do not begin until they 
are six or seven years old, and sometimes even later. Stuttering may arise 
from imitation, and probably inheritance is an occasional factor. It is 
frequently a mark of degeneration. 

It is important that all such cases receive early treatment before 
the habit becomes firmly fixed. The prognosis is good for sponta- 
neous recovery in nearly all the cases seen in very young children, 
and also in those coming on after acute illness. Other cases in which 
the condition has become habitual, should have the benefit of syste- 
matic training under a competent teacher in breathing, vocal, and speech 
gymnastics. 

Stammering. — This term is sometimes used synonymously with stut- 
tering. Kussmaul makes the distinction between them that, in stammer- 
ing, individual sounds are difficult of production, while in stuttering it is 
syllabic combinations. Stammering is often accompanied by some defect 
in the organs of articulation — the teeth, lips, tongue, or palate — which 
is not present in stuttering. 

The treatment consists in careful training and in the correction of 
whatever abnormal local conditions may exist. 

Lisping. — In this there is imperfect production of certain sounds, 
owing usually to a faulty position of the organs of articulation. The 
sounds may be so indistinct that fchey can not be understood. In this 
condition also there may be defective formation of some of the organs of 
articulation, although in the milder forms this is not the case. The treat- 
ment is similar to that of stammering. 



692 DISEASES OF THE NERVOUS SYSTEM. 

Alalia. — This consists in a total inability to articulate. It is seen in 
all young infants during their earliest attempts at talking. In older 
children it is usually associated with some mental defect. 

Backwardness. — Backwardness is carefully to be distinguished from a 
late development of speech due to idiocy. At two years old children not 
deaf are almost invariably able to speak. Speech may be late in conse- 
quence of prolonged or very severe illness, and where it has been acquired 
it may be lost from similar causes. 

Functional Aphasia. — The term has been applied to a temporary loss 
of speech which sometimes occurs in chorea, and sometimes from severe 
fright or anything else which has produced a marked nervous im- 
pression. West records an instance in a girl of eight years, who was 
suffering from an attack of chorea induced by fright. Speech first be- 
came difficult and then was lost altogether. For a month the child could 
say only " Yes " and " No." The case very slowly improved, but at the end 
of nine weeks had recovered completely. 

Loss of speech sometimes follows the acute infectious diseases, espe- 
cially typhoid fever. 

In all disorders of speech, the functional cases are to be distinguished 
from those which depend upon deafness and mental deficiency. The 
frequency with which these disorders are due to disturbances of general 
nutrition, and to local causes in the mouth and throat, should be borne 
in mind, and these conditions should receive their appropriate treatment 
early, before the habit of defective speech becomes firmly established. 
For the latter class of unfortunates, special training at the hands of a 
competent teacher should be advised, preferably in an institution. 

DISORDERS OF SLEEP* 

Disturbed Sleep, Sleeplessness. — Disturbed or restless sleep is much 
more common in infancy and childhood than is true insomnia, although 
the causes of the two conditions may be the same. 

Etiology. — In infancy these symptoms are most frequently due to 
hunger or to indigestion resulting from overfeeding or improper feeding. 
Very often disturbed sleep is the result of bad habits, such as rocking 
during sleep or night-feeding. Sometimes it arises from dentition, or the 
pain of colic or otitis ; at other times it may be simply the expression of a 
condition of nervous irritability, the result of inheritance or of the child's 
surroundings. 

In later childhood the first thing to be suspected when sleep is much 
disturbed is some derangement of the digestive organs ; in this will be 
found the explanation of fully half the cases. The most frequent type, 

* For the characteristics of the sleep of infancy, and the average amount taken at 
the different ages, see pages 5 and 6. 



DISORDERS OF SLEEP. 693 

where the symptom is of long duration, is chronic intestinal indigestion, 
often associated with indicanuria, a condition in which the diagnosis of 
the mother is usually worms. Other cases are due to obstructed respira- 
tion from adenoid growths of the pharynx or enlarged tonsils, sometimes 
to nocturnal attacks of asthma. A lack of fresh air in the sleeping room, 
excessive or insufficient bedclothing, and cold feet, are other frequent 
causes. Disturbed sleep with " starting pains " is one of the earliest 
symptoms of hip-joint disease. In the nervous exhaustion resulting 
from overpressure in schools, and in malnutrition and anaemia, dis- 
turbances of sleep are well-nigh constant. They are also seen in organic 
cardiac disease and in all pulmonary conditions accompanied by dysp- 
noea or cough. Sleep may be disturbed in consequence of bad dreams 
which have their origin in exciting stories heard or read just before bed- 
time, or in too violent or exciting play. To discover the cause in almost 
any case it is necessary to investigate carefully the whole routine of the 
child's life. 

Symptoms. — The condition may be one of real insomnia which may 
last for weeks or months ; or the sleep may be simply disturbed and rest- 
less, the child waking many times during the night, and when asleep will 
not lie quietly, but constantly changes his position. Sometimes children 
wake suddenly with a scream, but immediately drop oh* to sleep again. 

Treatment. — The essential treatment consists in the discovery and re- 
moval of the cause of the disturbance. This will often involve a radical 
change in the manner of feeding, in the hygiene of the nursery, and in 
all the surroundings of the child ; but in this way only should these cases 
be managed. Under no circumstances should the physician countenance 
the use of drugs to promote sleep in children, except in the case of severe 
acute disease. Soothing sirups and all nostrums for " teething " should 
be absolutely forbidden. Mothers and nurses are only too ready to fall 
into the habit of using them, because the injurious effects are not appre- 
ciated. When the cause of sleeplessness is found and removed the child 
will sleep, but compulsory sleep obtained under other conditions is always 
productive of more harm than good. If food, diet, and all bad habits 
have been corrected, nervous causes must be investigated. When no cause 
can be discovered the treatment should consist in putting the child upon 
the simplest possible diet, and in attention to such general conditions as 
anaemia, malnutrition, and neurasthenia, some of which arc almost certain 
to be present. In many cases a warm bath at bed-time will be found bene- 
ficial. A quiet, darkened room, plenty of fresh air, and the stopping of 
both eating and drinking during the night, are essential to a cure in most 
cases. When the condition accompanies some acute disease, the drugs 
which are most useful are codeia and trional. A child of two years may 
take -gJg- of a grain of codeia or two grains of trional as an initial dose, to 
be increased if necessary. 



694 DISEASES OF THE NERVOUS SYSTEM. 

Night Terrors— Pavor Nocturnus. — Two classes of cases have been 
grouped under this head, both having this in common, that sleep is dis- 
turbed by fright. In an excellent recent article upon this subject,* Coutts 
calls attention to the necessity of sharply distinguishing between them. 

The condition in the first group partakes of the nature of nightmare. 
It may be due to partial asphyxia from adenoid growths of the pharynx, 
or to other causes mentioned under disturbed sleep, or it may be gastric or 
intestinal in its origin. These cases are quite frequent. Sleep may be 
disturbed from the outset, and the attack may be merely the culmination 
of such disturbance. The child wakes in a state of fright and excitement, 
and often says he has had a bad dream. His mind is clear, he recognises 
those about him, but it may be a long time before he is sufficiently calm 
to sleep again. The attack may be remembered perfectly the next day. 
Cases like this are to be managed in the same general way as cases of dis- 
turbed sleep above mentioned. 

In the second group are the only cases, to which the term " night ter- 
rors" should really be applied. These are relatively rare, but the condi- 
tion is a much more serious one. The symptom is due to some dis- 
turbance of the central nervous system. According to Coutts, it occurs 
especially in those of neurotic antecedents, or those who have previously 
suffered from infantile convulsions, and it is often the precursor of other 
nervous attacks, — migraine, hysteria, epilepsy, and even insanity. The 
attack usually comes suddenly where a child has previously been sleep- 
ing quietly, and more frequently in the early part of the night than later. 
He is generally found sitting upright in his bed in a bewilderment of 
terror, being afraid of " the dog," or " the bear," or there is some other 
vision or hallucination which has produced the fright. Often this is asso- 
ciated with something of a red colour. The child does not recognise 
those about him, does not know w r here he is, and may go to sleep again 
without coming to full consciousness. The next day there is no recollec- 
tion of what has happened. Usually no after-effects are seen, but some- 
times a large amount of pale urine is passed. The attacks may be re- 
peated at intervals of a few months, or they may occur every few nights ; 
but whatever the peculiar nature of the vision, it is likely to be repeated 
in nearly the same form. Such attacks have something in common with 
epileptic seizures, and the diagnosis between them may at times be diffi- 
cult. They are always to be regarded seriously, not only on account of 
what they are in themselves, but on account of what may follow. 

Treatment. — All mental and nervous strain should be most carefully 
avoided, and where the attacks are frequent the bromides should be given 
at bedtime. Some person should sleep in the same room with the child, 
or in an adjoining one with the door open. 

* American Journal of the Medical Sciences, February, 1896. 



INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 695 

Excessive Sleep. — It is rare that either infants or children sleep an un- 
natural amount of the time unless one of two causes is present — organic 
brain disease or the use of drugs. The latter is always to be suspected if 
with the sleep there is associated obstinate constipation. Opium in the 
form of " soothing sirup " or paregoric, is the drug which has usually been 
given. 

INJURIOUS HABITS OF INFANCY AND CHILDHOOD. 

On account of the close connection of these habits with disturbances 
of the nervous system, they may be properly considered with the func- 
tional nervous diseases. Although some of these habits may not be of 
serious importance, yet as a group they have received altogether too little 
attention at the hands of the physician. 

Sucking. — This is a very common habit in infants, and during the first 
few months it is seen to some degree in most of them. If they are care- 
fully watched the habit is easily stopped ; otherwise it may continue in- 
definitely. Young infants usually suck the fingers when hungry, and this 
can scarcely be considered abnormal, but an effort should always be made 
to stop it, lest the habit become fixed. Lindner * distinguishes between 
simple sucking and sucking with combinations. In the former, the child 
sucks some part of the body, such as the thumb, fingers, toes, tongue, lips, 
back of the hand or arm, or it may be some foreign substance, such as 
part of the clothing, the blanket, a rubber nipple, or a " sugar-teat." This 
is the most common form that is seen. In the second variety the suck- 
ing is accompanied by the rubbing of some other parts, which seems to 
afford a pleasurable excitement ; this may be the ear, the genitals, or any 
other portion of the body. Sometimes sucking is accompanied by some 
practice which produces actual pain, such as pulling of the hair or scratch- 
ing the body. Habits of sucking often persist throughout infancy, and 
not infrequently throughout childhood ; they have often been known to 
continue up to puberty. The longer the habit has lasted the more diffi- 
cult is it to break. 

The results of sucking may be serious. Deformities of the thumb or 
finger, of the lips and teeth, and even of the jaws, are sometimes pro- 
duced. I know a lady, now in advanced life, whose thumbs to this day 
show a deformity resulting from the habit of thumb-sucking while a child. 
In her case the habit was not broken until she was eight or nine years 
old. Probably the most pernicious result of sucking is its tendency to 
develop the habit of masturbation. Habitual sucking of one hand or 
finger may lead to spinal curvature. 

Treatment. — In the management of these cases the most important 
thing is to arrest the habit early, before it becomes fixed. Too often the 

* Juhrbuch fur Kinderheilkunde, vol. xiv, p. 08. 



696 DISEASES OF THE NERVOUS SYSTEM. 

habit of thumb-sucking, or of sucking a rubber nipple, is encouraged by 
mothers and nurses, because of the temporary quiet which is thereby 
produced; even physicians are sometimes accessory to this procedure. 
Under no circumstances should it be resorted to as a means of putting 
children to sleep or otherwise quieting the nervous system. Nurses 
and parents should be put on their guard. With infants, the only 
treatment which is at all successful is such mechanical restraint as will 
make sucking an impossibility. It is of no use to cover the part which 
is sucked with bitter solutions. My experience has been that children are 
not deterred even in the slightest degree by such procedures. The hands 
of young infants may be covered with mittens, or with the long sleeves of 
a night-gown which is pinned to the bed, so that it is impossible for the 
child to get the part to the mouth ; or pasteboard splints may be applied 
at the bend of the elbow, so as to prevent flexion of the arms. Children 
must be carefully watched at all times, but particularly when going to 
sleep and when they first wake, since these are the times when sucking 
is most likely to be indulged in. In the milder cases the habit is often 
discontinued spontaneously when infants are eighteen months or two years 
old ; but when it has been indulged until a child is four or five years old, 
it is broken only with the greatest difficulty and after prolonged effort. 
Punishments are of little avail, but rewards are often successful. The 
child's pride must be stimulated. Eestraint should be encouraged by every 
means possible. On no account should this be passed over as a trivial 
matter either by the parents or the physician. 

Masturbation. — This is not uncommon even in infancy. Many cases 
have been observed during the first year, and some as early as the seventh 
or eighth month. In the Babies' Hospital within the last three years at 
least half a dozen cases have been under observation in children under 
two years old, some of them most intractable ones. Masturbation is more 
frequent after the eighth or ninth year, but it is from the twelfth to the 
fifteenth that it is especially seen. At. this age it is much more often 
seen in males than in females, although in girls it is particularly hard to 
control. 

The symptoms which these older children exhibit who practise fre- 
quent masturbation, are usually marked and quite characteristic. They 
are pale and anamiic ; they have dark rings under the eyes ; they sleep 
poorly, are easily fatigued, and frequently complain of headaches. They 
become quiet, reticent, and easily embarrassed ; they avoid the society of 
other children, and lose all animation and all interest in out-of-door 
amusements. They are absent-minded, and show an inability to concen- 
trate the attention upon anything. Gradually they may become more and 
more morbid, and in extreme cases may develop melancholia, mental weak- 
ness, or even insanity. In other cases, attacks of convulsions and epilepsy 
may follow. I had recently under observation a boy of seven years who 



INJURIOUS HABITS OF INFANCY AXD CHILDHOOD. 697 

was having from six to ten epileptic seizures a week, in whose case mas- 
turbation appeared to be the principal cause. I do not, however, think 
such cases are frequent. Sometimes hysteria and chorea are traceable to 
the influence of masturbation, this result being, of course, more likely to 
follow where there already exists a predisposition to these diseases. In 
addition to these effects upon the nervous system, where it is begun at 
an early age, masturbation may seriously interfere with the physical de- 
velopment of the child. The local symptoms of masturbation in the 
male, are redness and sometimes slight swelling of the prepuce ; but very 
often there is simply a relaxed condition of all the genital organs. In the 
female there may be redness and swelling of the vulva, and in some cases 
a moderate vaginitis. 

Among the local causes may be mentioned anything which excites 
undue irritation, — a long or adherent prepuce, phimosis, balanitis, vagini- 
tis, any skin disease which causes itching of the part, thread-worms, and 
even constipation. Urine which is rendered irritating on account of ex- 
cessive acidity or the presence of crystals of uric acid, is a not infrequent 
cause. Exercises in which the legs are rubbed together may lead to it, also 
posture or clothing which causes friction of the parts, and sometimes warm 
feather-beds. To these must be added as a potent cause, the habit of suck- 
ing. Masturbation often results from example or because the habit has 
been taught by other children, sometimes by nurses. Where it develops in 
a young child without local cause, it should not be forgotten that mas- 
turbation is one of the signs of degeneration, often an early one, and other 
stigmata (page 758) will usually be found if they are looked for. 

In infants and very young children masturbation is often not recog- 
nised. At this age it is more frequently accomplished by thigh-friction, 
or by rubbing the genitals against a chair or some other object, than by 
the use of the hands. The variety of ways is almost endless. During the 
act there are usually noticed flushing of the face and some rigidity of the 
muscles of the trunk and lower extremities, which are followed by complete 
relaxation and often by perspiration. 

The prognosis depends most of all upon how firmly rooted the habit 
has become before it is recognised. It is usually a simpler matter to stop 
it in infants and in young children, as they can be more easily controlled 
and more closely watched than those who are older. The outlook is much 
better where the cause is a local one capable of being removed, than 
where no such cause exists. It is also much better when in an older child 
it has been acquired by imitation, than where it is a symptom of degen- 
eracy ; in fact, the last-mentioned cases are rarely it* ever cured. 

Treatment. — The most important thing is an early recognition of the 
condition. The physician should put parents and nurses on their guard, 
and the first suspicions should be reported and the child carefully watched 
until all doubt is removed. In most cases seen by the physician the 



(398 DISEASES OF THE NERVOUS SYSTEM. 

habit is not difficult to arrest at the outset, but it becomes extremely so 
after it has been practised for years before it is discovered. In young 
infants much may be accomplished by mechanical restraint. The kind 
of restraint which is necessary will depend upon the manner of mastur- 
bating. If by the hands, these must be tied during sleep, so that the 
child can not reach the genitals ; if by thigh-friction, the thighs must 
be separated by tying one to either side of the crib. In inveterate cases, 
a double side-splint, such as is used in fracture of the femur, may be ap- 
plied. In children that are over three years old, all such contrivances are 
almost invariably unsuccessful. It is of the utmost importance in every 
case to have the child under the close surveillance of a competent and 
trustworthy person. He should be especially watched just after being put 
to bed and immediately after waking. Corporal punishment is often use- 
ful in very young children, but of little or no benefit in those who are over 
four years old. In fact, in such it may do positive harm, for deception 
and lying are soon added to the previous vice. The mother should secure 
the child's confidence, and in every way possible seek to strengthen his 
will and stimulate his self-control, using her influence to help him break 
the habit. The local causes, too, must be examined into and removed 
whenever found. Circumcision should be done if phimosis exists, and 
even where it is not, the moral effect of the operation is sometimes of 
very great benefit. Care should be taken that the clothing does not 
irritate the parts. The child should be removed from all vicious com- 
panions. In some cases hypnotism has been employed with excellent re- 
sults. The general treatment should be directed to the child's condition. 
Cold bathing should be practised, iron and tonics administered where they 
are indicated by the general condition, and the child should be put under 
as healthful local surroundings as possible. The administration of drugs 
for the habit itself is of little or no value. 

Nail-biting and Tongue-sucking are two forms of habit which are less 
frequent and less important than those already mentioned. The former 
is best remedied by keeping the nails cut very short ; the latter seldom 
becomes a fixed habit, and the child usually ceases it of his own accord as 
he grows older. 



MALFORMATIONS. 



699 



CHAPTEE III. 

DISEASES OF THE BRAIN AND MENINGES. 

.MALFORMATIONS. 

The malformations of the brain are of great variety, and many of 
them are solely of anatomical interest, as the conditions are incompatible 
with life. Only the most frequent and the best-known types will be men- 
tioned, and those which are of interest from a clinical point of view.* 

Meningocele, Encephalocele, and Hydrencephalocele. — These three con- 
ditions have in common a protrusion of some part of the -cranial contents 





Fig. 110.— Meningocele. 



\ 
Fig. 111. — Encephalocele. 

through an opening in the skull. In 
meningocele (Fig. 110) there is protru- 
sion of the membranes alone. These 
form a sac, which is usually, but not 
invariably, distended by fluid. In en- 
cephalocele (Fig. Ill) there is a pro- 
trusion of a portion of the brain sub- 
stance; this is connected with the rest 
of the brain by a constricted neck or 
pedicle. There may or may not be 
fluid present in the tumour. In hy- 
drencephalocele (Fig. 112) there is a 
protrusion of a portion of the brain substance which contains within it 
a cavity filled wi tli fluid, this cavity communicating with the distended 
lateral ventricles. 




Fig. 11 2. — Hydrencephalocele. 



* For other forms see Sachs, Nervous Diseases of Children, 1895, pp. 589-G07. 




700 DISEASES OP THE NERVOUS SYSTEM. 

In all these conditions there is a tumour, usually pedunculated, of a 
round or pyriform shape, with a smooth or lobulated surface. The ordi- 
nary size is that of a mandarin orange ; it may be as small as a walnut, or 
as large as the patient's head, It is generally covered by the scalp, which 
is often denuded of hair ; but it may be covered only by granulation- 
tissue, or it may show a central cicatrix, like that of spina bifida. Its 
coverings are usually thin and translucent. Other deformities, such as 
spina bifida, club-foot, and hare-lip, are frequently present. 

All these conditions are rare, but the most frequent and most serious 
one is hydrencephalocele, this being usually associated with hydrocephalus. 
The next in frequency is encephalocele, which has the best prognosis. 
This is frequently termed hernia cerebri. It may exist without very serious 
alteration in the cranial contents. If fluid is present, it is external to 
the brain. Meningocele is the rarest form, and consists simply of an 

accumulation of fluid in the arach- 
noid cavity, which communicates by a 
small opening with the general arach- 
noid cavity of the brain. 

Of one hundred and five cases col- 
lected by Schatz, fifty-nine occupied 
the occipital region and forty- six were 
frontal. The aperture through which 
the occipital protrusion takes place is 
IIJP*"^ usually in the median line. It may 
J!! communicate with the posterior fon- 

I BL tanel, with the foramen magnum, or 

^ miW ^- with the cleft of a spina bifida. The 

Fig. ii3.-Naso-frontai meningocele (after occipital bone may be divided in the 

Demme). \ J 

median line, or rarely it may be absent. 

In the naso-frontal form (Fig. 113) the tumour is usually at the root 
of the nose, a little to one side of the median line. The aperture is most 
frequently between the cribriform plate of the ethmoid and the frontal 
bones. It may be between the lateral halves of the frontal bone, causing a 
median tumour. The point of protrusion may also be the lateral region 
of the skull, generally about the lateral fontanel, or along the line of the 
sutures ; it may project into the mouth or the pharynx. These anterior 
tumours are usually small, although large ones containing the anterior 
lobes of the brain, have been seen. 

The theory of the origin of these malformations which is most widely 
accepted is that they are primarily cases of intra-uterine hydrocephalus, 
and as the cranial cavity has gradually been closed by the development 
of the bones, a certain portion of the brain has been left outside. 

Symptoms. — The tumour is always congenital, although after birth 
it frequently increases very much in size. A typical tumour is round 




MALFORMATIONS OF THE BRAIN". 701 

and elastic, usually giving evidences of fluid ; it pulsates synchronously 
with the heart ; during screaming or forced inspiration, it increases in 
size ; partial and in some cases complete reduction is possible, but this is 
usually followed by marked cerebral symptoms, even by convulsions. After 
partial reduction, an opening in the skull may often be made out. Micro- 
cephalus may be present, or there may be unequal development of the two 
sides of the head. 

The following differential points given by Treves, indicate the most 
characteristic features of the three varieties : In meningocele, the tumour 
is at first small, but increases ; it has a smooth surface ; it is pedunculated ; 
there is distinct fluctuation, perfect translucency, rarely pulsation ; often 
it is completely reducible ; compression of the tumour causes cerebral 
symptoms; the skull is normal. In encephalocele, the tumour is small 
and smooth ; it is rarely pedunculated ; fluctuation is absent ; it is not 
translucent ; there is distinct pulsation ; it is usually reducible ; pressure 
causes cerebral symptoms; the skull is normal. In hydrencephalocele, 
there is a large pendulous tumour with an irregular or lobulated sur- 
face ; it is pedunculated ; translucency is rarely complete ; fluctuation is 
distinct ; it is irreducible ; pressure rarely causes symptoms ; microcepha- 
lus and other deformities are often associated. 

The occipital tumours are usually more serious than the frontal ones. 
The majority of cases die in the course of the first few weeks of life, 
death resulting from meningitis, convulsions, or rupture. In meningocele 
the tumour usually grows slowly, and ultimately may be shut off from the 
cranial cavity ; but gradual thinning of the membrane may take place, and 
spontaneous or accidental rupture occur. In encephalocele the tumour 
grows slightly, or not at all. Most of these patients exhibit signs of 
mental impairment or other evidences of organic brain disease. 

Treatment. — According to Treves, operation is justifiable only in case 
of impending rupture. The conditions present are essentially the same 
as in spina bifida. Meningocele may be aspirated, injected with iodine, 
or with Morton's iodine and glycerin solution (page 765) ; the sac may be 
laid open and a plastic operation performed for the closure of the com- 
munication with the cranial cavity ; or the skin may be divided, and a 
ligature or clamp applied to shut off the communication with the brain. 
All these methods have been at times successful, but cure lias in many in- 
stances been followed by the development of chronic hydrocephalus. Kn- 
cephalocele is to be treated by protection and compression. Aspiration 
may be resorted to if fluid is present. Id hydrencephalocele the prognosis 
is absolutely bad under all circumstances. Schatz* gives the following 
statistics, showing the results with and without operation, all varieties 
being included : Of twenty-four occipital tumours not operated on, three 



* Berlin. Win. Wochenscrift, No. 28, L886. 



702 DISEASES OF THE NERVOUS SYSTEM. 

recovered ; of thirty-five operated on by excision, ligation, or injection, 
six recovered. Of forty-six frontal tumours, there were six recoveries in 
thirty-two cases without operation, and two recoveries in fourteen cases 
with operation. 

Microcephalus. — This is generally regarded as due to premature ossi- 
fication of the skull ; but this theory is certainly inadequate to explain 
all the cases. In many children suffering from marasmus, the sutures 
ossify and the fontanels close much earlier than in healthy infants of 
the same age, chiefly because, with the rest of the body, the brain also 
has ceased to grow. So it is true of some of the cases, at least, of micro- 
cephalus, that the early ossification of the skull is due to arrested growth 
of the brain, and not the reverse. The reasons for the developmental 
arrest in the brain are for the most part unknown. The condition usually 
dates back to intra-uterine life, although in some cases it appears to begin 
after birth. 

It is well known that there is not an invariable relation between the 
size of the head and the size of the brain, although generally the two cor- 
respond. If the circumference of the head is much below the average for 
the age (page 20), and relatively much less than the measurements of the 
rest of the body, microcephalus may be assumed to exist. Sachs calls 
attention to the fact that the circumference of the head may be nearly 
normal and yet the essential conditions of microcephalus exist, owing to 
imperfect development of the anterior part of the brain. 

The symptoms of microcephalus are those of idiocy and cerebral 
paralysis, existing in all possible combinations and with variable degrees 
of severity. 

A new surgical interest in these cases has been awakened- during the 
last few years by the operation of craniectomy. The purpose of this oper- 
ation, which was devised by Lannelongue, is to relieve the intracranial 
pressure by making a longitudinal opening in the skull, on one or both 
sides. The opening made is usually about half an inch wide and four 
or five inches long. It is one or two inches from the sagittal suture, to 
which it is parallel. For the time being the cranial capacity is increased, 
but it is doubtful if even this is permanent. Jacobi* gives a report of 
thirty-three cases operated upon by American surgeons, with fourteen 
deaths and nineteen recoveries. At the time of report the condition in 
the cases which survived the operation was as follows : no improvement 
in seven ; slight, in seven ; " some," in one ; much, in two ; no history, in 
one ; uncertain, in one. I quite agree with him that such results do not 
justify the performance of this operation. 

Congenital Hydrocephalus.— These cases may fairly be considered as 
belonging to this category, although they have been discussed elsewhere. 

* New York Medical Record, May 19, 1894. 



PACHYMENINGITIS. 703 

Porencephalia (literally, a hole in the brain) is a condition in which 
there is a large depression in some part of the brain, but with surrounding 
parts well developed. Such depressions may involve a whole lobe, and 
they may be deep enough to reach the lateral ventricles. 

Porencephalus is described as congenital or acquired. In the congeni- 
tal form, the defect is usually found in the anterior or middle part of the 
brain. The origin of these conditions is still a disputed question. They 
are probably due to early vascular changes. Children sometimes live 
several years with very large defects, the symptoms depending upon the 
seat of the lesion. The acquired form of porencephalus is usually one of 
the late results of meningeal haemorrhage. It may affect one or both 
sides. Such cases present the symptoms of spastic paralysis — usually 
diplegia. In all cases with large brain defects, the space is filled with fluid. 

PACHYMENINGITIS. 

Pachymeningitis, or inflammation of the dura mater, occurs both as 
an acute and a chronic disease. 

Acute Pachymeningitis. — This is very rare in children. Only pachy- 
meningitis externa is generally included under this term, as acute pachy- 
meningitis interna does not occur alone, but usually with inflammation of 
the pia mater (leptomeningitis). It may be associated with disease or 
injury of the bones of the skull, but is most frequently seen in connection 
with middle-ear disease. It generally begins as a localized process, but 
the inflammation may extend to the inner layer, and to the pia mater ; or 
it may remain circumscribed, and terminate in the formation of an abscess 
between the dura mater and the bone. 

The symptoms of acute pachymeningitis are distinctive only when the 
process is localized. They are then usually associated with middle-ear 
disease, and are indistinguishable from those of cerebral abscess. The 
treatment is surgical. 

Chronic Pachymeningitis. — This, in children, almost invariably affects 
the inner layer (pachymeningitis interna) ; it is also known as pseudo- 
membranous and as hemorrhagic pachymeningitis or hcematoma of flu' 
dura mater. Its causes are for the most part unknown. It is not very 
rare, being usually discovered at autopsy in children, chiefly cachectic 
infants, who have died of other diseases. In the Report of the New York 
Pathological Society for 1890 Northrup records six such cases. I have 
seen five similar ones, as well as one other associated with chronic hydro- 
cephalus. 

Two classes of cases are to be distinguished, — those with, and those 
without extensive haemorrhages. In the latter group there is found a thin, 
translucent, vascular membrane lining the inner surface o| the dura. It 
may be only a delicate film which can be scraped off; it may be as thick 
as ordinary blotting-paper, or even twice that thickness. The membrane 



704: DISEASES OF THE NERVOUS SYSTEM. 

is often ceclematous ; it is exceedingly vascular, and the vessels have very 
thin walls. There are usually scattered, punctate haemorrhages, and 
there may be a few of larger size. This membrane may cover the whole 
inner surface of the dura, but in most cases it is principally over the con- 
vexity and may be found only here ; it is apt to be more upon one side 
than upon the other. In cases of long standing there may be adhesions 
between the dura and the pia. When large haemorrhages have taken place, 
quite a different pathological appearance is presented. The lesions found 
in a case upon which I made an autopsy in the New York Infant Asylum, 
are fairly typical : The infant was six months old, and the symptoms had 
existed for six days. The fontanel was bulging to a marked degree, and 
the sagittal and coronal sutures were separated. A thin recent clot from 
one eighth to one fourth of an inch in thickness covered nearly the whole 
of the right hemisphere and part of the convexity of the left. The entire 
dura was lined both at its convexity and base by a pseudo-membrane of 
grayish color, about one sixteenth of an inch in thickness. The brain 
was anaemic. 

In. cases of longer standing partial organization of the clot may be 
seen ; in more recent ones the blood is partly or entirely fluid. I once 
found acute leptomeningitis with a purulent exudation, associated with 
hemorrhagic pachymeningitis. In cases where life is prolonged for years, 
there may be partial or even complete absorption of the clot, followed by 
the formation of cysts, considerable inflammatory thickening of the pia 
with deposits of blood pigment, and finally atrophy and sclerosis of the 
cortex. The source of the haemorrhage may be the rupture of a single 
large vessel, but more frequently the blood comes from many small 
vessels. 

Symptoms. — These are due to the haemorrhage, and not to the inflam- 
matory process. Until haemorrhage occurs there are no symptoms by 
which the disease can be recognised. Thus in many of the cases in which 
pachymeningitis is found at autopsy, its existence is not suspected dur- 
ing life. The occurrence of haemorrhage is sometimes marked by vomit- 
ing or convulsions, and usually there is loss of consciousness. It may 
be a question whether the convulsions are the cause or the result of 
the haemorrhage. In most cases they seem to be the result. They are 
usually general and repeated. If the haemorrhage occurs slowly, there 
may be stupor without convulsions until nearly the close of the disease. 
In the fatal cases the symptoms generally continue from two days to a 
week. There are dulness, stupor, and finally coma, death occuring in coma 
or convulsions. If the haemorrhage is diffuse — and this is apt to be the 
case — there is rigidity of all the extremities ; if it is of one side only, the 
rigidity affects only one arm and leg. The pupils are more frequently 
contracted, but may be dilated or unequal. There is diplegia, hemi- 
plegia, or monoplegia, according to the seat and extent of the haemor- 



PACHYMENINGITIS. 705 

rhage. The respiration is slow and irregular and may be of the Cheyne- 
Stokes variety. The pulse is slow, irregular, and sometimes intermittent. 
The temperature is at first normal, but rises slowly until death occurs, 
when it is from 100° to 103° F. Generally the cranial nerves are not 
affected, and opisthotonus is absent. The knee-jerk is often exagger- 
ated. In cases which do not prove fatal — these being chiefly in older 
children — we have a similar onset, but after a few days consciousness is 
regained, and only hemiplegia or monoplegia remains. The course of the 
paralysis is that seen after meningeal haemorrhage due to other causes. 
Wagner has reported a case in which recurring haemorrhages took place 
at intervals of several months, the autopsy showing distinct evidences of 
both old and recent lesions. 

Pachymeningitis, I believe, plays a much more important role in the 
production of meningeal haemorrhages in children than has generally been 
accorded to it. From the frequency with which this lesion is found as a 
cause of sudden meningeal haemorrhages which are fatal, it is not unlikely 
that many of the cases which recover with hemiplegia or monoplegia, may 
be due to the same cause. 

The prognosis depends upon the age of the patient and the extent of 
the haemorrhage. Extensive haemorrhages are usually fatal in infancy, 
but small ones are seldom so, for they are rarely at the base. The prog- 
nosis of the paralysis in cases not terminating fatally, is the same as after 
meningeal haemorrhage due to other causes, with perhaps an added liabil- 
ity to recurrent attacks. 

Without large haemorrhages, pachymeningitis interna can not be diag- 
nosticated ; and it is impossible to differentiate the haemorrhagic cases 
from other varieties of meningeal haemorrhage. It is important to make 
a diagnosis between pachymeningitis with haemorrhage, and acute simple 
meningitis. In the former we have a sudden onset ; stupor occurs early, 
usually on the first day, gradually diminishing in cases of recovery, or 
deepening into coma in fatal cases ; localized or general paralysis, also 
occurring early; there is no fever in the beginning, and only moderate 
fever at the close. In acute meningitis we usually have a higher tem- 
perature, especially early in the disease ; coma develops later, and rigidity 
of the extremities is less pronounced. In certain cases, however, where 
the haemorrhage occurs in the course of some other disease, a differential 
diagnosis may be impossible. 

Treatment. — The treatment of pachymeni ngitis hemorrhagica is symp- 
tomatic. The indications are, to relieve cerebral congestion by applying 
ice to the head, to allay irritative symptoms by the use of bromides, and 
to keep the patient perfectly quiet. 



54 



706 DISEASES OF THE NERVOUS SYSTEM. 

ACUTE MENINGITIS. 

Acute inflammation of the pia mater, or acute leptomeningitis, is seen 
under a variety of circumstances : 

1. It occurs epidemically. It is then usually associated with the same 
process in the cord, and is known as cerebrospinal meningitis, or spotted 
fever, being regarded by many as a general infectious disease with a local 
lesion. 

2. It occurs sporadically as a primary disease, with symptoms and 
lesions which may be identical with those seen in the first group of 
cases. 

3. It occurs as a secondary disease, complicating other acute infectious 
diseases and local inflammations. 

At the present time we are not able to separate absolutely these three 
groups by the clinical symptoms, the pathological findings, or even by a 
bacteriological study of the micro-organisms which are concerned in the 
process. All the forms will therefore be considered under the same gen- 
eral head. 

Etiology. — Epidemic meningitis occurs especially in winter and 
spring; it affects children of all ages, but males more often than fe- 
males. It is attributed to overcrowding, especially in damp, ill- ventilated 
apartments, and, in some epidemics, to bad drainage and sewer-gas poi- 
soning. It is not contagious, in the ordinary acceptance of the term. Epi- 
demics are usually separated by intervals of several years, and when they 
occur the number of persons attacked is rarely large. In New York 
cases are seen every year ; but in some seasons the number is quite large, 
and the disease is then said to be epidemic. 

Sporadic cases of meningitis may result from traumatism or sun- 
stroke, or they may occur without assignable cause after the disease has 
prevailed epidemically, or even where there has been no epidemic. In the 
great majority of cases no adequate cause can be discovered. 

Acute meningitis occurs as a secondary disease, complicating pneumo- 
nia, scarlet fever, variola, influenza, and typhoid fever. I once saw acute 
simple meningitis as a complication of pulmonary tuberculosis. It not 
infrequently complicates acute nephritis, especially when this has followed 
scarlet fever. It may be secondary to otitis media, erysipelas of the scalp, 
or abscess of the brain. 

The bacteriological findings in the cases of cerebro-spinal meningitis 
thus far have not been uniform. The micro-organism most frequently 
found has been the pneumococcus (micrococcus lanceolatus). Some re- 
cent writers are inclined to regard this as the characteristic germ of epi- 
demic meningitis. The pneumococcus, however, is found in sporadic cases, 
even in pure culture, as in one of my own patients, an infant of thir- 
teen months ; but, on the other hand, during the winters of 1893 and 



PLATE XV. 




Acute Meningitis, complicating Pleuropneumonia. 

Child twenty months old ; on twenty-third day of a protracted attack of pneumonia, 
vomited six times, and the temperature, which had been nearly normal for four days, 
rose to 103° F. On the following day general convulsions, which were repeated fre- 
quently during the next few days; temperature, 101° to 104° F. ; death in convulsions 
on twenty-eighth day. 

Autopsy. — Pleuro-pneumonia of left side ; lung resolving. Anterior portion of 
brain enveloped in lymph and pus, more marked at the convexity, but present also 
over the base. 



ACUTE MENINGITIS. 707 

1894, when the disease was regarded as epidemic in New York, Biggs 
found that in cases observed in one hospital (Bellevue) with similar symp- 
toms and with the same gross lesions, there was no uniformity in the bac- 
teriological findings. The pneumococcus was present in some, in others 
the streptococcus or staphylococcus, each form usually existing in pure 
culture in the case in which it was found. 

While the pneumococcus is undoubtedly the micro-organism most fre- 
quently concerned in ejndemic meningitis, it is certainly not the only one. 
In sporadic cases also it plays the most important part. Of twenty- 
five such cases studied by better, the pneumococcus was found in eighteen, 
the streptococcus pyogenes and staphylococcus pyogenes albus in four, 
and various other bacteria in the remainder. In the secondary cases, the 
pneumococcus is usually found when meningitis complicates pneumonia 
or influenza. Under other circumstances, any of the varieties of pyogenic 
bacteria may be met with. 

Lesions. — In the most severe cases, and especially w T hen the disease is 
prevailing epidemically, death may take place so early that the changes 
found at autopsy are slight. There may be only a serous exudation and 
intense hyperemia, this being much less marked after death than during 
life. The microscope, however, may show, even in these early cases, an 
abundant exudation of leucocytes in the pia mater. In other cases, espe- 
cially in infants, we may find an extensive purulent exudation where the 
symptoms have apparently lasted only twenty-four hours. In cases of 
three or four days' duration the lesions are quite uniform. The con- 
volutions appear somewhat flattened from pressure due to distention of 
the ventricles. The inner surface of the, dura is usually normal or only 
congested. There may be thrombi in any of the cerebral sinuses, or in 
the meningeal veins of the convexity. The brain is enveloped in an 
exudation of greenish-yellow lymph, which is usually abundant, and may 
nearly conceal the convolutions (Plate XV). It is generally most marked 
over the anterior half of the brain, and at the base, occurring elsewhere 
in patches. Exceptionally it may be found only at the base or at the 
convexity, but usually it is very extensive. There is an increase in the 
quantity of cerebro-spinal fluid. The ventricles are moderately distended 
with serum or sero-pus, and their walls may be slightly softened. To the 
naked eye the brain substance may show no changes except some con- 
gestion of the superficial layers of the cortex. In the meninges of the cord 
lesions similar to those of the brain are usually seen. The exudation is 
principally upon the posterior surface, and may extend throughout the 
entire length of the cord, or be limited to its upper or to its lower portion. 
In some cases the cord lesion is overlooked, because the whole cord is not 
exaumied. 

Microscopical examination shows the exudation to consist of fibrin 
and pus cells, which infiltrate the pia mater and may cover its surface. 



708 DISEASES OF THE NEIiVOUS SYSTEM. 

The superficial layers of the cortex in the inflamed areas sometimes show 
minute haemorrhages and very marked cell-infiltration. Extension from 
the meninges to the substance of the cord is less common. Inflamma- 
tory products may be found in the central canal of the cord, and occa- 
sionally in the walls of the lateral ventricles of the brain. The lesions 
most frequently found in other organs, are acute parenchymatous degen- 
eration of the liver, spleen, and kidneys, pneumonia, pleurisy, and peri- 
tonitis. 

In sporadic cases of meningitis the lesions are identical with those 
above described. In the secondary cases, as a rule, the cord escapes, 
although the lesions in the brain are usually the same as when the disease 
is primary. When meningitis occurs as an extension from otitis, it be- 
gins in most cases as a localized process, and afterward becomes general. 
It is usually complicated by septic thrombosis of the lateral sinuses. 

In the cases of meningitis which recover, there is an absorption of 
the greater part of the inflammatory products ; but the pia mater may 
be thickened and adherent to the brain ; areas of sclerosis may develop in 
the cortex, and chronic hydrocephalus may follow. I have three times had 
the opportunity of making autopsies upon cases which died at periods 
varying from four months to a year after the original attack of meningitis. 
There were found in all of them, thickening and cloudiness of the pia mater, 
usually most marked at the base. No remains of the exudation were seen 
except small deposits of fat occurring in irregular patches at the base and 
the convexity, not unlike miliary tubercles. This was seen in regions 
where the lesions had been most intense. In one case dying six months 
after the acute attack, the pia was adherent over the entire cortex of the 
brain;* the microscopical examination showed a thickening of the pia 
mater with an exudation of cells between the pia mater and the brain, 
and in places a commencing secondary encephalitis. A continuance of 
such a process as this may give rise to a localized or a diffuse sclerosis 
which may impair the functions and growth of the brain. Such lesions 
are most frequently seen over the frontal and temporo-sphenoidal lobes. 

Symptoms.— Few diseases are so irregular in their course and present 
so many atypical forms, as does acute meningitis. 

1. The common form.— Most of the sporadic and epidemic cases are 
of this type. The acute symptoms are sometimes preceded by a prodro- 



* The clinical features of this case were also interesting. The patient was a bright 
little girl of four and a half years, who had in May a typical attack of meningitis of 
moderate severity. She made a very slow convalescence, but at the end of two months 
recovery was perfect in everything but her mental condition. She remembered noth- 
ing which she had previously learned in the kindergarten, where she had been an ex- 
ceptionally bright pupil. Her mind was a blank. She was dull, listless, and her face 
had a vacant, idiotic expression." The special senses seemed unaffected, and speech 
was retained. She died during an attack of convulsions in November. 






ACUTE MENINGITIS. 709 

mal stage of one or two days, characterized by general weakness and in- 
definite malaise, but in the majority this is wanting, and the attack begins 
suddenly with vomiting or convulsions, headache, and high fever. The 
initial temperature is from 102° to 105° F. There are present intense head- 
ache, marked prostration, pain in the back of the neck and along the 
spine, general hyperesthesia, opisthotonus, constipation, retraction of the 
neck, and rigidity of the cervical muscles. Later, more intense nervous 
symptoms develop. There is delirium, which is often active, to which are 
added muscular twitchings, and sometimes convulsions : or there may be 
dulness, apathy, and finally complete coma. The respiration is slow, 
sometimes irregular. The temperature is elevated, usually between 101° 
and 104° F. There are seen in a few of the cases fine petechial spots 
upon the face, abdomen, or all over the body. The pupils are irregular ; 
there may be strabismus or nystagmus. The pulse is weak, and some- 
times slow, sometimes rapid. 

After these symptoms have lasted from two to ten days, the patient 
may become completely comatose, with general relaxation and dilated 
pupils, and may die in this condition or in convulsions. In other cases 
he passes into a typhoid condition, and death occurs from exhaustion or 
complications, particularly pneumonia. The usual duration of these attacks 
is from one to two weeks. If the case recovers there is a gradual subsi- 
dence of the nervous symptoms and sometimes quite a rapid convales- 
cence ; or the disease may pass into a subacute form, lasting from three 
weeks to two or three months, improvement being slow and interrupted 
by relapses. Severe cases may be followed by deafness, localized paralysis, 
or an impaired mental condition. 

2. Abortive cases. — In every epidemic there are seen attacks which be- 
gin precisely like those above described, but where the symptoms last 
only two or three days and then subside rapidly, the case going on to 
a complete and permanent recovery. In some epidemics the number of 
such cases is quite large. 

3. Malignant or fulminating cases. — These also occur principally in 
epidemics, but are not confined to them. The onset in this type is very 
abrupt, and the patient may be overcome by the poison and die in from 
twelve to thirty-six hours. These cases often begin with convulsions and 
very high temperature, from 104° to 10G"5° F. There is very groat pros- 
tration and frequently cyanosis. There may be opisthotonus and general 
hyperesthesia, or these may be absent. The patient may pass in a IVw 
hours into a condition of collapse, with general relaxation, feeble, irregu- 
lar pulse, and cold extremities, followed by convulsions and death. If 
life is prolonged, there may follow after a few hours a period of reac- 
tion, in which irritative symptoms arc prominent, — headache, photopho- 
bia, contracted pupils, general hyperesthesia, and active delirium. The 
eruption may appear within the first twenty-four hours after the onset. 



Y10 DISEASES OF THE NERVOUS SYSTEM. 

In mostof these cases a positive diagnosis is impossible, as the general 
toxic symptoms mask the local evidences of cerebral inflammation. 
The diagnosis is not likely to be made except when the disease is pre- 
vailing epidemically. 

4. Acute primary meningitis occurring sporadically does not differ 
in any essential particulars from the epidemic form. The fulminating 
and the abortive cases are, however, less frequent than when the disease is 
epidemic. 

5. Acute secondary meningitis presents quite a different clinical pic- 
ture, and the symptoms are greatly modified by those of the original dis- 
ease. In general, its course is shorter, and it is more uniformly fatal than 
is primary meningitis. The diagnosis is difficult, and in many cases the 
lesions are found at autopsy where no marked cerebral symptoms have 
existed during life. This is particularly true where the process is mainly 
at the convexity. The onset is generally with convulsions, after which 
there may develop quite rapidly stupor and finally coma, with dilated 
pupils, slow pulse, and irregular respiration. Convulsions and gradually 
deepening stupor may be the only symptoms ; or there may be opisthoto- 
nus, retracted abdomen, and rigidity of the extremities. The duration 
of these cases is quite short, being rarely more than three or four days, and 
often but one or two. Death usually occurs in convulsions. 

The nervous symptoms. — Headache is a frequent symptom of menin- 
gitis and is often severe ; it is more likely to be frontal than elsewhere, 
although it may be general and associated with vertigo. There may also 
be pains in the back of the neck, along the spine, or in the muscles, which 
may be so intense as to cause the patient to scream out. Pain may be 
present only in the early stage, or continue throughout the disease. With 
this there may be tenderness along the spine, and often general hyperes- 
thesia, which may be so acute that any movement causes agonizing cries. 
Delirium is frequent in the severe cases after the first day ; it may be wild 
and active, or low and muttering. After delirium there follows usually a 
stage of apathy which may develop into complete coma ; deep coma, how- 
ever, is not often present in cases that recover. Convulsions mark both 
the onset and the close of the disease, but rarely occur during its progress. 
Tonic spasm of the various muscles gives rise to deformities which may 
continue through the attack. The rigidity and contraction of the muscles 
of the neck produces cervical or general opisthotonus ; there may be tonic 
flexion or extension of the extremities, especially of the legs. In some 
epidemics opisthotonus is seen in nearly every case, in others it is infre- 
quent. In most of the protracted cases localized paralysis is present in the 
course of the disease. It may affect one side of the body, or one extremity. 

Special senses. — The eyes are affected in almost all severe attacks. The 
pupils in the early stage are generally contracted, later they may be irreg- 
ular, and toward the close they are usually widely dilated. External 



ACUTE MENINGITIS. 711 

strabismus is by far the most frequent form of ocular paralysis. The 
fundus is rarely normal. In a study of thirty-five cases, Eandolph 
(Baltimore) noted the following changes: The fundus was the seat of 
venous engorgement and tortuosity, with more or less congestion of the 
optic disc in nineteen cases ; there was optic neuritis in six cases ; 
retinitis with thrombosis of the central vein in one case. Of the seven 
cases in which the fundus was normal, one had strabismus, one nystagmus, 
and one greatly dilated pupils. Inflammation of the conjunctiva is also 
very frequent. Deafness is common during the acute stage of the disease, 
and is its most frequent sequel. It may be due to the cerebral lesion, to 
otitis media, or to otitis interna. The last mentioned may result from an 
extension of inflammation along the course of the auditory nerve. 

Speech is disturbed in most of the protracted cases. Bulging of the 
fontanel is one of the regular symptoms in young infants. Marked pros- 
tration is always present; it may come very abruptly, and maybe fol- 
lowed by collapse, or may last but a short time and be followed by a period 
of reaction. 

The temperature is always elevated, being especially high at the onset. 
In the fulminating cases there may be hyperpyrexia, — 105° or even 106° F. 
The usual range is between 100° and 104° F. In cases terminating in 
recovery, the fever usually lasts from one to two weeks and gradually falls 
to normal. There is no regular or typical curve. The height of the tem- 
perature may bear no relation to the severity of the other symptoms. It 
may be low throughout, even in the fatal cases. A subnormal temperature 
is also a bad sign. 

The respiration is slow and irregular as the disease progresses, and it 
may be of the typical Cheyne-Stokes variety. Cyanosis is often present 
in cases where no cause for it can be found in the heart or lungs ; it is 
especially frequent in the fulminating cases. Pneumonia is one of the 
most common complications. 

The pulse in the early stages is full and rapid ; later it becomes slow, 
irregular, and feeble, and may be intermittent. 

The examinations of the blood made by Barker and Flexner (Balti- 
more) showed the presence of marked leucocytosis in every fatal case 
examined. Epistaxis is not uncommon as an early, and sometimes as a 
late, symptom. 

Digestive system. — Vomiting is frequent at the onset and may be per- 
sistent. The bowels as a rule are constipated, although there may be 
diarrhoea, and as a complication even dysentery has been observed. The 
tongue is often coated; sometimes it is dry and glazed, or covered with 
sordes. Deglutition is sometimes difficult on account of the retraction 
of the neck. The spleen is usually not enlarged. Jaundice occurs in a 
small proportion of the cases. 

Eruptions. — In the majority of cases, the skin presents no changes 



712 DISEASES OF THE NERVOUS SYSTEM. 

In others there is herpes of the lips, face, or nose, or an eruption over the 
face or body consisting of fine purpuric spots, and sometimes larger ex- 
travasations. These are particularly significant when seen upon the face 
or the ears, and from this symptom the name " spotted fever " has arisen. 
In some cases a general erythema is present. The petechial eruption may 
be seen during the early part of the disease, even in the first twenty-four 
hours. Late in the protracted cases there may be fine punctate haemor- 
rhages over the abdomen, as in any exhausting disease. 

The large joints, particularly the knees, are often swollen, tender, and 
painful, the symptoms resembling those of acute rheumatism. Inconti- 
nence of urine and faeces may occur in the late stages of the disease, asso- 
ciated with low delirium and other typhoid symptoms. Retention of urine 
is not infrequent, and often overlooked. 

Course, Termination, and Prognosis. — The duration of the disease in 
the fatal cases is usually less than a week. In epidemics many deaths 
occur within forty-eight hours. In infants also the course is very short. 
Of the cases which terminate in recovery, if we exclude the abortive cases, 
the majority last at least two weeks, and very many run a protracted course. 
After three or four weeks, there is in such cases a gradual subsidence of 
the fever and of most of the acute nervous symptoms ; but the child re- 
mains emaciated, very weak, with occasional attacks of headache, general 
pains or hyperesthesia, and often with some localized paralysis. This 
may slowly disappear, or it may be permanent. The child may recover 
perfectly so far as all the physical functions are concerned, but be mentally 
deficient. 

The sequelae of meningitis relate chiefly to the nervous system. There 
may be hemiplegia or monoplegia, followed by contractures, which may 
be temporary or permanent. Of the special senses, hearing is most liable 
to be affected, deafness being quite common after severe attacks, and deaf- 
mutism not an infrequent result in young children. Blindness is rare, 
and may be due to optic-nerve atrophy or rarely to the cerebral lesion. 
Speech is sometimes affected ; and all grades of mental disturbance are 
seen after an attack. As a late result epilepsy may develop. 

Meningitis is usually more fatal when it occurs epidemically than in 
sporadic cases. The mortality in different epidemics varies from thirty to 
seventy-five per cent. The younger the patient the worse the prognosis, 
and in infants the disease is usually fatal. 

Diagnosis. — The diagnosis of acute meningitis presents unusual diffi- 
culties in young children, because of the frequency with which cerebral 
symptoms are seen in all forms of acute disease, both at the onset and late 
in their course. In infants the usual mistake made is to diagnosticate 
meningitis where there is none, rather than to overlook it when it is 
present. The symptoms most to be relied upon for diagnosis, are con- 
tinued stupor or coma, opisthotonus, slow pulse and irregular respiration 



ACUTE MENINGITIS. 713 

— especially if associated with high fever — localized paralvsis, rigidity of 
the extremities, and a retracted abdomen. Cases where the principal 
lesion is at the convexity are particularly obscure, and the diagnosis often 
is not made duriug life. There is no opisthotonus or cranial-nerve symp- 
toms, and irregularity of pulse and respiration are rare. 

At the onset, meningitis is most likely to be confounded with pneu- 
monia, scarlet fever, and influenza. Pneumonia is recognised by the 
accelerated respiration and the physical signs ; scarlet fever, by the con- 
gestion of the throat and the eruption ; from influenza the diagnosis may 
be almost impossible except from the course of the disease. From all other 
diseases, meningitis is differentiated by the continuance and the severity of 
the nervous symptoms, rather than by the presence or absence of single or 
special symptoms. 

Quincke's procedure of lumbar puncture of the spinal canal* furnishes 
a means of differential diagnosis of considerable value. It is especially 
useful in distinguishing meningitis from other diseases accompanied by 
marked cerebral symptoms. In meningitis there is invariably found, 
according to Wentworth (Boston), a distinct cloudiness of the cerebro- 
spinal fluid. In some cases this is very marked, in others it is so slight 
as to require careful comparison with distilled water in a test-tube, to make 
it apparent. In addition there may be found during inflammation an 
excess of albumin, a deposit of leucocytes, and any of the various bacteria 
which produce meningitis. 

A differential diagnosis between epidemic meningitis and the sporadic 
form is impossible. The diagnosis of simple from tuberculous meningitis 
is easy in typical cases, but in certain forms of the disease it is extremely 
difficult and sometimes impossible. The most striking points of contrast 
are, that in simple meningitis the onset is usually abrupt ; the temperature 
is high ; the disease develops rapidly ; and in forty-eight hours— sometimes 
in twenty-four— nearly all the severe nervous symptoms may be present; 
pain in the spine and general hyperesthesia are quite frequent. Usually 
the patient is a child who has been in perfect health up to the beginning 
of the disease; or there is present some local cause, such as middle-ear 
disease, or traumatism ; or an epidemic may be prevailing. In tuberculous 
meningitis, the onset is usually insidious; the temperature low; the pros- 



* Puncture is usually made between the third and fourth lumbar vertebra a little 
to one side of the median line. The Bmallesl exploring needle may be used, and for 
convenience it may be attached to a syringe as a handle, as it is not necessary to aspi- 
rate. The canal is reached at a variable depth, nsnally aboui one inch from the skin. 
The body should be flexed during the operation s<> as to separate the vertebra, and 
unless the patient is comatose an anaesthetic is advisable. All observers agree thai 
with a clean needle lumbar puncture is harmless. See Jacoby, New fork Medical Jour- 
nal, December 2s. L895, and January 1. L896; Caille\ New York Medical Journal, June 
15, 1895; and Went worth, Transactions <>f the American Padiatric Society, l s '.'<;. 



714 DISEASES OF THE NERVOUS SYSTEM. 

tration not marked for the first few days ; the evolution of the nervous 
symptoms is often slow and irregular, and the child may be sick a week 
before he appears to be seriously ill ; pain in the spine and general hyper- 
esthesia are rare. The child is usually one who has a history of heredi- 
tary tuberculosis ; or who has been previously delicate, or who has suffered 
already from some other form of tuberculosis, in the lungs, bones, or 
lymph nodes. In cases of sporadic meningitis which are apparently pri- 
mary, the tuberculous is much more frequent than the simple form, — in 
my experience fully three to one. 

Treatment. — The treatment of acute meningitis is quite unsatisfactory, 
and it is very doubtful whether the result is greatly modified by any spe- 
cial plan of treatment ; it seems to depend upon the age of the patient, 
and the nature and severity of the attack, rather than upon its manage- 
ment. The treatment directed toward the inflammation consists in the 
constant use of an ice-cap to the head, and at times an ice-bag along the 
spine. Counter-irritation may be maintained by painting the nape of 
the neck and the spine daily with a strong tincture of iodine, or by blis- 
ters, but best of all by the Paquelin cautery. The bowels should be kept 
freely open by calomel or saline cathartics. Internally, ergot and iodide 
of potassium should be given in as full doses as will be tolerated by the 
stomach. 

Of the symptoms which call for special treatment, the most prominent 
one is pain, which when severe requires morphine, often in large doses. 
It is often best to give it hypodermically. For other nervous symptoms — 
delirium, sleeplessness, etc. — the bromides and chloral, sulfonal, or trional 
may be given, or warm sponge baths. Stimulants are required in most of 
the cases at some time in the course of the disease. They are indicated 
by weak, rapid, and irregular pulse. Alcohol and digitalis should be 
used, but not strychnine. The difficulties in feeding these patients are 
sometimes great, but they can often be overcome by the use of gavage 
(page 62), which may be advantageously employed as a routine practice in 
the most severe cases. The physician should be on the watch for bed- 
sores, and endeavour to prevent them by cleanliness, frequently changing 
the patient's position, etc. The bladder also must not be forgotten, as 
retention of urine is not uncommon, and may require the use of the 
catheter. 

For the residual paralysis, massage, warm baths, and friction should be 
employed, but electricity only when all symptoms of central irritation 
have subsided. The prolonged use of iodide of potassium seems to have 
considerable influence in promoting absorption of the inflammatory prod- 
ucts in cases where there is a persistence of symptoms for two or three 
months. 



TUBERCULOUS MENINGITIS. 715 

TUBERCULOUS MENINGITIS. 
Synonyms : Acute hydrocephalus ; basilar meningitis ; water on the brain. 

Tuberculous meningitis is a tuberculous inflammation of the pia mater 
of the brain, sometimes involving also that of the cord. It is doubtful if 
it ever occurs as the only tuberculous lesion of the body. It is quite 
frequently seen, and is more uniformly fatal than any other disease of 
early life. In infancy it is usually associated with general or pulmonary 
tuberculosis ; in older children with tuberculosis of the bones, joints, or 
lymph nodes. Of my own cases, twenty five per cent of all deaths from 
tuberculosis in children, were due to meningitis. 

Lesions. — The lesion consists in the production of miliary tubercles, 
with which are frequently found tuberculous nodules of variable size, and 
in almost every case there are also the products of ordinary inflamma- 
tion of the pia mater — lymph and pus — together with an accumulation of 
fluid in the lateral ventricles of the brain. Frequently there are tubercles 
in the pia mater of the upper portion of the cord. The miliary tu- 
bercles appear as small gray or white granules, situated along the vessels 
of the pia mater. When few in number they are usually only at the base, 
especially along the Sylvian fissures and in the interpeduncular space. 
When numerous they are most abundant at the base, but are also seen 
scattered over the convexity in small groups. In about half of my au- 
topsies they have been limited to the base, and in no case were they seen 
exclusively at the convexity. Tubercles are often found in the choroid coat 
of the eye. The amount of lymph and pus present is rarely great, and 
never equal to that seen in simple acute meningitis. It is often a 
matter of surprise at autopsy to find the lesions so few, after very marked 
symptoms. The inflammatory products are most abundant at the base. 
In addition to the patches of greenish-yellow lymph, there are adhesions 
between the lobes of the brain and thickening of the pia. In cases which 
have lasted for several weeks, the pia mater in places is often very much 
thickened, owing to cell infiltration and the production of new connective 
tissue, and it is studded with miliary tubercles, sometimes with small yel- 
low tuberculous nodules; frequently there is arteritis, which is sometimes 
obliterating. 

In the most acute cases the brain substance immediately beneath the 
pia is intensely congested, slightly softened, and shows under the micro- 
scope a superficial encephalitis. The lateral ventricles are usually dis- 
tended with clear serum, sometimes with serum containing Qocculi of 
lymph or pus; the amount present varies from one to four ounces in each 
ventricle, being always greater in the suhacnte cases. The walls of the 
ventricles may be softened. The distention of the ventricles leads to 
flattening of the convolutions from pressure against the skull, to bulging 



716 



DISEASES OF THE NERVOUS SYSTEM. 



of the fontanel, and sometimes to separation of the sutures, if they are not 
completely ossified. 

Tuberculous nodules varying in size from a small pea to a walnut are 
frequently seen associated with meningitis in older children, but not so 
often in infants. These nodules may be connected with the meninges, or 
they may be situated within the brain substance, usually in the cerebel- 
lum. The larger ones are classed as brain tumours. Inflammatory prod- 
ucts are rarely found in the spinal canal. 

Although it is not infrequent to see meningitis without symptoms of 
tuberculosis elsewhere, I have never failed at autopsy to find other tuber- 
culous lesions in the body. In my own experience the following are those 
most often met with, given in the order of frequency: 

(1) In infants, associated with general or pulmonary tuberculosis; (2) 
in children from three to twelve years of age, with tuberculosis of the 
vertebrae, hip, knee, or ankle ; (3) at any age, with tuberculosis involving 
only the tracheal, bronchial, or cervical lymph nodes ; (4) much less fre- 
quently with the pulmonary tuberculosis of older children. Meningitis 
has been reported when it was secondary to tuberculosis of the skin or 
mucous membranes. I have not, however, met with such cases. 

Etiology. — Tuberculous meningitis is produced only by the transpor- 
tation of the tubercle bacilli to the brain. They may find their way by 
the blood-vessels or lymphatics. 

The following table shows the age at which the disease is most fre- 
quently observed : 



Age. 



Under one year 

One to two years 
Two to five years 

Five to nine years 

Nine to sixteen years 

Totals 



Personal cases. 



14 

9 

24 

15 

5 



67 



Oxley. 



3 
16 
26 
18 





63 



Total. 



17 
25 
50 
33 
5 



130 



In this series, males were a little more frequently affected than fe- 
males. In two or three instances traumatism was apparently an exciting 
cause. Tuberculous meningitis is occasionally seen in young children who 
were previously healthy, whose family history is free from tuberculosis, 
and where no exposure can be traced. It is probable that in all such cases 
there has been latent tuberculosis somewhere in the body, and that the 
exposure was long antecedent to the symptoms. In the majority, how- 
ever, this is not the case. There is usually a history of hereditary tuber- 
culosis or of exposure to infection ; or there have been previous evidences 
of tuberculosis in the lungs, bones, or lymph nodes. 



Liverpool, Medico-Chirurgical Journal, July, 1885. 



TUBERCULOUS MENINGITIS. 71 Y 

Symptoms. — In forty-three of sixty-three cases the onset was gradual ; 
but in a considerable number of those classed as sudden, careful inquiry 
elicited a history of previous indisposition. The most frequent early 
symptoms are disinclination to play, or drowsiness ; sometimes there is 
constant fretfulness or irritability. Often a distinct change in disposition 
is seen. In a case recently under observation this was most striking; 
from being devoted to her mother, a little girl could not endure her presence 
in the room. There is loss of appetite, and usually constipation. Sleep 
is restless and disturbed ; there may be grinding of the teeth. Older 
children often complain of headache. At all ages a suggestive symptom 
is frequent attacks of vomiting without apparent cause. In addition to 
these there may be a slight but continuous elevation of temperature. In- 
definite symptoms may last for four or five days, or they may be spread 
over two or three weeks without perhaps being sufficiently severe to attract 
much notice. Finally, unmistakable evidence of brain disease develops, 
and then it is recollected that symptoms like the above had existed for 
some time. These early disturbances are often ascribed to dentition, to 
worms, or to indigestion ; and sometimes they are regarded simply as 
the result of the constipation. 

In the midst of such indefinite symptoms there may come an attack of 
convulsions, and, in the course of a few hours, deep stupor. The early 
symptoms of the active stage are indicative of cerebral irritation. There is 
headache, often located in the frontal region, and occasionally photophobia ; 
sometimes there is sudden screaming out at night without waking. The 
skin is usually somewhat hypersesthetic ; the reflexes are apt to be exagger- 
ated ; the muscles of the neck may be rigid and the head is drawn back, or 
there may be rigidity of one or more of the extremities. The pupils are 
normal or contracted ; there may be nystagmus. The child is fretful, 
wishes to be left alone, and cries if disturbed ; but otherwise is apt to be un- 
naturally drowsy. Such symptoms may continue for a day or two, or even 
for a week. If prolonged, they are likely to alternate with periods of more 
marked apathy and dulness. During this stage there is occasional vomit- 
ing, and the bowels are obstinately constipated. The pulse is usually 
somewhat accelerated, but may be slow and occasionally is irregular. The 
respiration is of normal frequency, but a careful observation during sleep 
or perfect quiet will often show a slight irregularity which is very signifi- 
cant. This becomes more marked as the disease progresses. The tem- 
perature is invariably elevated, but never very much BO, generally being 
from 99° F. to 101° P. When a high temperature is seen, it is usually 
due to tuberculosis elsewhere. 

During the intermediate or seeond Btage, the irritative symptoms hill- 
side, and stupor becomes deeper and more continuous, [f undisturbed, 
the child may sleep a greai part of the time, hut can In- roused, and then 
appears quite rational. Later the stupor becomes so profound that the 



718 DISEASES OF THE NERVOUS SYSTEM. 

child can not be roused at all; or, again, this condition may alternate with 
periods of complete lucidity. Active delirium is rare. The pupils respond 
slowly to light or not at all ; they may be unequal ; occasionally there is 
strabismus, ptosis, or even paralysis of the face. More often there is hemi- 
plegia, or paralysis of one arm or leg. Such paralyses are often transient, 
disappearing after a day or two. Automatic movements of the extremi- 
ties, particularly of the arms, are frequent. Muscular twitchings may be 
noticed. Opisthotonus is marked and well-nigh constant. In infants 
the fontanel is tense and bulging ; the abdomen is retracted, giving the 
typical " boat-belly." On drawing the finger-nail along the skin of the 
abdomen, there appears, after a few seconds, a distinct red streak one or 
two inches wide, which remains for three or four minutes. This is the 
tache cerebrate, and while not pathognomonic, it is almost always present. 
Other vaso-motor disturbances maybe seen. The reflexes are variable; 
in the early part of the disease they are usually increased, later they are 
diminished or abolished. The pulse now becomes slow and irregular, 
often intermittent. The respiration assumes the characteristic type, which 
consists in the movements becoming deeper and deeper until there is 
a long sigh, then a complete arrest of respiration for several seconds, after 

which the movements begin again, 
at first shallow, but gradually in- 
creasing in depth until the sigh 

Fig. 114.— Tracing of respiration in tuberculous j s repeated. The accompanyino; 
meningitis. . . , 

tracing illustrates the type (Fig. 
114). An examination with the ophthalmoscope usually shows the pres- 
ence of choked discs. 

The duration of this stage is from three to ten days. The progress 
is irregular, and subject to great variations, especially as regards the 
mental symptoms. Sometimes a child will be seen in quite deep stupor, 
and on the following day will be sitting up in bed playing with its toys. 
Such a course is to be expected, and the physician should never raise 
any false hopes of recovery because of these periods of temporary improve- 
ment. 

In the third stage there is complete coma. The child can not be 
roused at all. The pupils are widely dilated, and do not respond to light. 
There is general muscular relaxation. There may be retention of the 
urine. Deglutition is difficult, sometimes almost impossible. The boat- 
belly and opisthotonus are still marked. The respiration is more rapid, 
but still irregular. There are sordes on the lips and teeth, emaciation, 
and anaemia. Toward the end the temperature rises rapidly to 104° F., 
sometimes to 106° or 107° F. (Fig. 115). The pulse becomes very rapid 
and feeble, often 160 to 180 a minute. Death usually takes place from 
exhaustion in deep coma ; or convulsions develop and continue from twelve 
to twenty-four hours until death. The duration of the stage of coma is 



TUBERCULOUS MENINGITIS. 



719 



from two days to a week. Often the patient will live for four or five days 
in a condition of prostration so extreme that death is hourly expected. 
A. rapidly rising temperature or the occurrence of convulsions indicates 



DAY 




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2 


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17 


DATE 


OCT. 


10 


11 


12 


13 


14 


15 


16 


17 


18 


19 


20 


21 


22 


23 


24 


25 


26 


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Fig. 115. — Fairly typical temperature curve in tuberculous meningitis ; boy, twenty months 
old; death on seventeenth day. 

approaching death. Of fifty-seven cases, fifty died in coma, seven in con- 
vulsions. 

The entire duration of the disease from the beginning of definite 
symptoms, in sixty-five of my own cases, was as follows : 

One week, or less 17 

One to two weeks 15 

Two to three weeks 17 

Three to four weeks 14 

Five weeks 2^ 

65 

Variations in the course of the disease. — There are few diseases which 
present a greater variety of symptoms than tuberculous meningitis. Typical 
cases like those above described are seen most frequently in children over 
two years old, in whom the cerebral symptoms predominate over those of 
general tuberculosis. In infancy, especially when the disease follows 
acute tuberculous pneumonia, the duration of the cerebral symptoms may 
be only three or four days. The stages then are not marked. The onset 
is usually with convulsions, and in less than twenty-four hours there may 
be marked stupor, and all the symptoms belonging to the third stage of 
the disease. 

In some cases the course is much longer than thai described, the 
symptoms lasting from four to eight weeks. In character they are much 
the same as those in the typical cases, except that the irritative symptoms 
are less marked, and there is* less fever, [f the child is young, there is 
great bulging of the fontanel, or even an increase in the size of the head. 



720 DISEASES OF THE NERVOUS SYSTEM. 

In older children the symptoms are chiefly those of a general pressure 
upon the cortex. These are due to the great accumulation of fluid in the 
lateral ventricles. The symptoms of general compression are persistent 
drowsiness, but rarely deep coma ; rigidity of all the extremities, some- 
times paralysis. The pupils are usually contracted, but there are no symp- 
toms which are distinctly focal. Opisthotonus is nearly always marked 
in these cases. 

Diagnosis. — There are no diagnostic symptoms in the first stage. If 
the patient has previously suffered from local or general tuberculosis, and 
symptoms develop which are enumerated as prodromal, meningitis may 
be suspected with a strong degree of probability. If the child has pre- 
viously given no evidence of tuberculosis, a diagnosis is impossible. The 
indefinite symptoms that belong to the early stage of the disease are fre- 
quent in young children suffering from chronic indigestion associated 
with constipation. In nine out of every ten cases, such will be the ex- 
planation of the indisposition rather than incipient meningitis. Dis- 
turbances of nutrition, classed as cyclic vomiting (page 287), may present 
many of the symptoms of meningitis. I have seen two cases in which a 
differential diagnosis was impossible for two or three days. 

The most important diagnostic symptoms of tuberculous meningitis 
enumerated in the order of frequency in fifty-eight cases, were as fol- 
lows : obstinate constipation, persistent drowsiness, irregular respiration, 
vomiting without apparent cause, irregular pulse, convulsions, opisthot- 
onus, and fever which was usually slight. The diagnosis is certain in 
proportion to the number of these symptoms present, and the degree of 
their development. 

The discovery of tubercle bacilli in the fluid drawn by lumbar puncture 
(page 713) is conclusive. However, this does not add greatly to our means 
of diagnosis, as the bacilli are never numerous and always difficult to 
find, and in a number of undoubted cases they can not be found at all. 
Without finding bacilli we may be quite certain, from the other conditions 
present, that meningitis exists, but we can not with any certainty separate 
the simple from the tuberculous cases. The symptoms which distinguish 
these from each other have already been considered (page 713). 

The cerebral symptoms of ileo-colitis and other diarrhoeal diseases, 
sometimes closely resemble those of tuberculous meningitis ; but whenever 
in a young child there is another disease present which may furnish an 
explanation for the cerebral symptoms, the diagnosis of meningitis should 
be made with great caution. The development of meningitis in the course 
of an ordinary attack of pneumonia may simulate very closely pulmonary 
tuberculosis with tuberculous meningitis. A diagnosis may be impossible 
during life. In doubtful cases the probabilities are greatly in favour of 
tuberculosis, since it is so much more common. 

Prognosis. — It is still a matter of dispute whether tuberculous menin- 



CHRONIC BASILAR MENINGITIS IN INFANTS. 721 

gitis ever ends in recovery. Such a result is certainly so rare as not to be 
expected. I have never seen it. In certain cases simple meningitis 
may so closely simulate the tuberculous variety that a differential diag- 
nosis can not be made, and it is possible that the cases of alleged recov- 
ery were simple and not tuberculous. Gibney has reported a case of men- 
ingitis occurring in a boy with double hip-joint disease, which certainly, 
so far as symptoms went, should be classed as tuberculous, and yet re- 
covery took place. The child died several months later, of amyloid dis- 
ease. I was present at the autopsy, and there was found no trace of cere- 
bral tuberculosis. On theoretical grounds there seems to be no reason 
why recovery may not sometimes follow from meningitis as well as from 
other forms of local tuberculosis, but as a matter of clinical observation 
such a result is extremely doubtful. 

Treatment. — From what has been said regarding prognosis, it follows 
that if the diagnosis is correct the case is practically hopeless, no matter 
what treatment is employed ; but as a positive diagnosis is not always 
possible, all cases should be treated like those of simple meningitis. 

CHRONIC BASILAR MENINGITIS IN INFANTS. 

Basilar meningitis is generally tuberculous. Xot very infrequently there 
is, however, seen in infants a chronic form of basilar meningitis which is 
not tuberculous. Attention was first called to these cases by Gee and Bar- 
low, who in 1878 published, under the title of " Cervical Opisthotonus in 
Infants," six cases of simple basilar meningitis in which the diagnosis was 
confirmed by autopsy. Since that time a number of other cases have been 
reported by various writers. I have followed two such cases to the post- 
mortem table, one of which was undoubtedly syphilitic. I have seen 
others of a similar nature which have recovered, one of these also being in 
a syphilitic infant. Not all these cases are syphilitic, but the etiology of 
the other cases is unknown. 

. Lesions. — This process is usually limited to the base of the brain. 
The pia mater is thickened about the interpeduncular space, also over the 
medulla, pons, and cerebellum. These different parts may be adherent to 
each other, or to the inner surface of the dura. The cranial nerves may 
be compressed. The openings in the fourth ventricle are usually obliter- 
ated, and there results a distention of the lateral ventricles with clear 
serum, sometimes in sufficient amount to be regarded as hydrocephalus. 
Rarely, pus may be found in the ventricles. The lesions thus are very 
much like those seen in the protracted cases of tuberculous meningitis, 
minus the tubercles. 

Symptoms. — These in all cases are quite uniform. The two most 
prominent symptoms are cervical opisthotonus and moderate hydroceph- 
alus. The opisthotonus is constanl and may he quite extreme. In one of 
my cases the cervical spine for weeks formed nearly ;i right angle with the 
55 



722 DISEASES OP THE NERVOUS SYSTEM. 

body. The accompanying illustration (Fig. 116) is from a photograph of 
this patient. From time to time the opisthotonus varies in intensity, but 
it never entirely disappears. The degree of hydrocephalus is generally 
not extreme. It causes the usual symptoms of enlargement of the head, 
separation of the sutures, and bulging of the fontanel. Mental dulness or 
apathy is less liable to be present when the disease begins in early infancy, 
and the cranial bones yield more readily to the increased pressure, than 
when it comes so late that the sutures are firmly ossified. In addition to 
these two cardinal symptoms, there are often seen nystagmus, occasional 
attacks of vomiting without apparent cause, and convulsions more or less 




Fig. 116. — Chronic basilar meningitis; a patient in the Babies' Hospital (diagnosis 
continued by autopsy). 

severe. There may be tonic rigidity of the extremities, with exaggeration 
of the reflexes. Febrile symptoms, as a rule, are wanting. The course is 
essentially chronic. The duration varies usually from one to four months ; 
exceptionally it may last a year. Patients may die from convulsions or 
from the effects of the hydrocephalus, but more frequently waste and die 
from marasmus. The prognosis is bad, except in the cases which are due 
to syphilis, where recovery may take place. How large a proportion of 
the cases are syphilitic has not yet been determined. 

Diagnosis. — The disease is to be distinguished from tuberculous menin- 
gitis, and from the opisthotonus of reflex origin, which is occasionally seen 
in infants suffering from marasmus. It differs from tuberculous menin- 
gitis in its more protracted course, in the absence of fever, paralysis, and 
the evidences of tuberculosis elsewhere in the body, and also in the greater 
prominence of the opisthotonus and hydrocephalus. The opisthotonus 
which is seen in cases of marasmus is never so extreme or so continuous, 



THROMBOSIS OF THE SINUSES OP THE DURA MATER. ?23 

and is not accompanied by any enlargement of the head, or by other 
cerebral symptoms. 

Treatment. — This consists in the administration of potassium iodide. 
Although this has little or no influence upon cases not syphilitic, it may 
cure those which are syphilitic. As it is impossible to distinguish be- 
tween syphilitic and non-syphilitic cases, every child should have the 
benefit of a thorough trial of this drug in full doses. At least fifteen 
grains daily should be given for several weeks to an infant six months old, 
and still larger doses if the stomach will tolerate it. 

THROMBOSIS OF THE SINUSES OF THE DURA MATER. 

This is not very frequent. It may depend upon certain general condi- 
tions, when it is usually classed as cachectic or marantic thrombosis ; it 
may be associated with local pathological processes, when it is known as 
inflammatory or septic thrombosis. 

Cachectic Thrombosis. — This is seen in infants and young children, 
but is very rare after the age of five years. It occurs in the course of 
various diseases, the most frequent being pneumonia, pertussis, diphtheria, 
nephritis, tuberculosis, and the acute intestinal diseases. In connection 
with the last-mentioned group, altogether too much has been made of it, 
as it is really rare, and in only a very few cases does it explain the cerebral 
symptoms present. This statement is made from personal observations 
upon over two hundred autopsies upon cases of acute intestinal disease. 
The actual cause of the thrombosis is the altered condition of the blood 
and the feeble circulation, as the walls of the sinuses are normal. 

The most frequent seat of cachectic thrombosis is the superior longi- 
tudinal sinus. At autopsy one must be careful not to confound the soft, 
partly-decolorized, non-adherent thrombi of post-mortem origin with those 
of ante-mortem formation. The latter are firm, and when of long stand- 
ing may be very hard and even show a laminated structure. They usually 
fill the sinus completely, and are adherent. The thrombus extends from 
the sinuses to the veins emptying into it, which stand out like dark worms 
upon the surface of the brain. The brain itself may be deeply congested, 
or it may be covered with a diffuse haemorrhage, but more frequently the 
brain and the membranes are simply cedematous. 

The symptoms of cachectic thrombosis are few and uncertain, and 
in a large number of cases the disease is latent. Very rarely is a posi- 
tive diagnosis possible during life. When the thrombosis occurs just 
before death, its symptoms arc so mingled with those of the original 
disease that they can not be separated. In some cases there may be 
localized or general convulsions, or paralysis, loss of consciousness, and 
strabismus. 

The prognosis is bad, eases generally proving fatal in the course of a 
few days. The diagnosis is so uncertain and obscure thai the treatment 



724 DISEASES OF THE NERVOUS SYSTEM. 

must be symptomatic, and directed toward the general rather than the 
local condition. 

Inflammatory Thrombosis — Septic Thrombosis— Sinus-Phlebitis. — This 
condition is most frequent in children in connection with acute meningitis. 
It may exist either with the simple or the tuberculous variety. It also fol- 
lows otitis — especially old and neglected cases — usually with necrosis of the 
petrous bone, but sometimes without it. It is much less frequently asso- 
ciated with disease of the ear in children than in adults. It may arise 
from traumatism, necrosis of the cranial bones, or from septic processes 
iuvolving any of the cavities or any of the structures adjacent to the brain, 
such as the scalp, orbit, nasal fossa, mouth, or pharynx. Infection from 
the mouth or pharynx is most frequent in children in connection with 
scarlet fever or diphtheria ; while usually secondary to otitis it may occur 
without it, the infection being carried by the blood-vessels. Infection 
from the nose may have its origin in ulceration from syphilis or tubercu- 
losis. In the orbit, the source may be malignant disease. 

The seat of the thrombosis will depend upon the original disease. If 
this affects the cranial bones or the scalp, it will be the longitudinal sinus ; 
if the ear, the lateral sinus ; if the base of the skull, the orbit, the mouth, 
the jaw, or the nose is affected, it will be the cavernous sinus. When 
thrombosis occurs with meningitis the lesions are much the same as in 
the cachectic form, with the exception that there are sometimes slight 
changes in the walls of the sinuses. If the patient has suffered from a 
local septic process, there may be puriform softening of the clot, and gen- 
eral pyaemia, with the development of secondary abscesses in the brain, 
in the lungs, and in other organs. With such cases there may be asso- 
ciated a general or localized meningitis. 

Symptoms. — The symptoms of septic thrombosis are more decided than 
those of the cachectic form. When occurring in the course of meningitis, 
it usually adds no new symptoms to those of the original disease. In the 
pyaemic form the symptoms are more characteristic, particularly when 
associated with otitis. There are recurring chills with very high and 
widely-fluctuating temperature. There is headache, and often localized 
tenderness of the scalp ; the other symptoms which are present are usually 
the same as those of meningitis. If metastasis occurs, there may be evi- 
dences of abscesses of the brain or in other organs, and sometimes there 
are signs of suppuration in the jugular vein. 

The local symptoms of the thrombosis differ somewhat according to 
the sinus affected : if its seat is the superior longitudinal sinus, there may 
be cyanosis of the face, dilatation of the temporal and frontal veins, and 
sometimes epistaxis ; if the lateral sinus is involved, the process may ex- 
tend to the jugular vein, which may be felt in the neck as a hard cord, 
and there may be dilatation of the veins of the mastoid region, aud even 
localized oedema ; when the cavernous sinus is affected, there may be pro- 



CEREBRAL ABSCESS. 725 

trusion of the eyeball of the affected side, oedema of the lid, and with the 
ophthalmoscope the retinal veins appear enlarged and tortuous, sometimes 
being the seat of thrombosis. The process may affect either one or both 
sides. The course of septic thrombosis is rather irregular, varying from a 
few days to three weeks. In fatal cases death takes place from menin- 
gitis, cerebral abscess, or pyaemia. The prognosis is very grave, unless the 
disease is so situated that it is accessible to surgical operation. 

Treatment. — The only successful treatment is surgical. Operation 
is easiest in thrombosis of the lateral sinus, being much more difficult 
if involving the superior longitudinal sinus. So many cases are now on 
record of successful operation upon septic thrombosis of the lateral sinus, 
that it should always be urged when the diagnosis is clear. Recurring 
chills and high, fluctuating temperature, associated with disease of the ear, 
either with or without symptoms of meningitis, are sufficiently character- 
istic to justify operative interference. 

CEREBRAL ABSCESS. 

Cerebral abscess is quite rare in children, decidedly more so than is 
cerebral tumour. In Gowers' collection of 223 cases, only 24 were under 
ten years of age. In infants, abscess is one of the least frequent diseases 
of the brain, and up to five years it is exceedingly rare. 

Etiology. — By far the most frequent cause in children is otitis. This 
is the origin of the great majority of the cases. Abscess rarely compli- 
cates acute otitis, but is seen with the chronic form. Exactly how otitis 
causes cerebral abscess it is not always easy to determine. Toynbee was 
the first to call attention to the fact that cerebellar abscess was most 
frequent with disease of the mastoid cells, and cerebral abscess with otitis 
media. Usually there is caries of the petrous bone, but there may be 
none. The infection may extend through the small veins traversing this 
bone, or along the lateral sinuses to the cerebellum. Abscess is often 
attributed to the retention of pus in the ear, but it may occur when the 
discharge is free. 

Traumatism is the second important etiological factor. Abscess may 
be associated with fracture of the skull, or follow simple concussion. The 
abscess is generally in the neighbourhood of the injury, but occasionally 
is produced by contre coup. In one instance, reported by Wagner, thrush 
was believed to be the cause of cerebral abscess, the same fundus that 
existed in the mouth being found in the brain, which in this case was 
studded with small abscesses. Abscess may be the result of infectious 
emboli, associated with general pyemia, though this is rare in early life; 
and finally it may occur without any assignable cause. 

Lesions. — The most frequent seat of the abscess is, first, the temporo- 
sphenoidal lobe; secondly, the cerebellum; thirdly, the frontal lobes. 
Other locations are very rare. Abscesses are usually single. In size they 



726 DISEASES OF THE NERVOUS SYSTEM. 

vary from that of a small cherry to an orange. One case was observed by 
Meyer, in which an abscess occupied one entire hemisphere. The con- 
tents are usually thick greenish-yellow pus, which may be very fetid. 
When abscesses have lasted for some time they are usually surrounded 
by dense pyogenic membrane, and may become encysted. The patho- 
logical process may be slow, and often is apparently stationary for a long 
period. Abscesses may rupture into the ventricles, less frequently upon 
the surface of the brain, causing meningitis, or the pus may even escape 
externally through the auditory meatus, as in Lallemand's case. 

Symptoms. — These are general and local. The general symptoms are 
much the more important for diagnosis, and often are the only ones present. 
The local symptoms are those of a tumour. The clinical history of a case 
of abscess of the brain may be divided into three stages : First, the period 
of onset, or early acute inflammatory symptoms, fever, etc., which attend 
the formation of pus. Secondly, the latent period, or period of remission^ 
in which very few symptoms are present. In many acute cases this stage 
is wanting altogether ; in the chronic cases it may last for months, or even 
years. Thirdly, the final period, with recurrence of active cerebral symp- 
toms, followed by death in a few days. 

The onset may be accompanied by symptoms so slight as almost to 
escape notice. In most cases, however, headache and fever are present. 
The headache is usually severe, and often localized upon the aifected side ; 
in cerebellar abscess it may be occipital. The fever is moderate in inten- 
sity, and continuous. In addition there may be vertigo, vomiting, gen- 
eral convulsions, and cessation of the aural discharge, if one has been 
present. The duration of this stage is variable ; it may be only a few 
days, or several weeks. It is shorter in traumatic cases, and in those which 
are due to pyaemia. 

The latent stage, or period of remission of symptoms may be quite 
short — only a few days' duration — and it is often absent. During this 
period the temperature may fall quite to the normal, and the headache 
disappear, or be only occasional and slight. However, if any focal symp- 
toms have been present they remain unchanged. 

The symptoms of the terminal stage are due to a rapid extension of 
the inflammatory process, with oedema and softening about the abscess, 
sometimes to rupture into the ventricle, and sometimes to meningitis. 
The fever now returns, and may be high. There is headache, often 
very intense and continuous; there may be delirium and convulsions, and 
the gradual development of coma. In addition there may be vomiting, 
paralysis, opisthotonus, retracted abdomen, and the other symptoms of 
meningitis. Occasionally all the earlier symptoms may be latent, and the 
terminal symptoms may be the only ones present. In infants, the fontanel 
is usually large and bulging ; convulsions are rather more frequent than 
in older children. 



CEREBRAL ABSCESS. 727 

The local symptoms of abscess are rather indefinite, owing to its usual 
situation. Abscesses of considerable size may exist in the temporo-sphe- 
noidal lobe, in the central part of the frontal lobe, or in the cerebellum, 
without any definite local symptoms. If the abscess is near the motor area, 
there are the usual symptoms of disease in this location, spasm, or paraly- 
sis of the face, arm, or leg. A cortical or sub-cortical abscess is likely to 
cause convulsions. Cerebellar abscess may give rise to occipital headache, 
frequent vomiting, and when the abscess is large enough to press upon 
the middle lobe, there may be inco-ordination of the muscles of the 
extremities. Optic neuritis may be present, but other symptoms relating 
to the cranial nerves are rare. Localized tenderness over the scalp, when 
persistent, is a symptom of importance, and may serve to locate the ab- 
scess, if it is superficial. 

Diagnosis. — Of the general symptoms, the most important for diagnosis 
are fever, headache, delirium, and terminal coma. These become particu- 
larly significant when following otitis or traumatism. The differential 
diagnosis of abscess is to be made principally from tumour and meningitis, 
and from these conditions more by the history and general course of the 
disease than by any special symptoms. The diagnosis of abscess from 
tumour is considered in connection with the latter disease. It is more 
difficult to distinguish between meningitis and abscess, since the two pro- 
cesses are often associated. With meningitis convulsions are more com- 
mon, but they are rarely localized ; rigidity and the inflammatory symp- 
toms are more intense ; the course is usually more rapid and more regular, 
being rarely interrupted, as is the course of abscess. From the cerebral 
symptoms occurring with otitis it is extremely difficult to distinguish 
abscess, for, according to Gowers, optic neuritis may be present in the 
former as well as in the latter condition. The more intense and pro- 
longed are the cerebral symptoms and the more marked the neuritis, the 
greater are the probabilities of abscess. 

Prognosis. — The prognosis in cerebral abscess is always grave, unless 
accessible to surgical operation. The progress may be slow, or rapid, but 
it is inevitably from bad to worse, and sooner or later the disease, if not 
interfered with, proves fatal. 

Treatment. — The medical treatment of abscess in its active stage is 
that of any acute intracranial inflammation, — ice to the head, absolute 
quiet, free catharsis, and full doses of the bromides or antipyrine or mor- 
phine, if pain is intense. The absolutely hopeless con. lit ion of these eases 
when left to themselves, and the recent brilliant results from surgical 
operations, should lead the physician to urge operation in every cs 



* For a discussion of the surgical aspects of tlii- question, see - Brain Surgery," by 
M. Allen Starr, M. D., and " Pyogenic Infectious Diseases of the Brain and Cord," by 

William McEwen, M. D. 



728 DISEASES OP THE NERVOUS SYSTEM. 



CEREBRAL TUMOUR. 

Very little has been added to our knowledge of cerebral tumour in 
children since the exhaustive monograph of Starr, which appeared in 
Keating's Cyclopaedia in 1890. It is to this article that I am indebted 
for most of the facts in this chapter. 

Varieties and Location. — Tumour of the brain is not very infrequent, 
and may be seen even in infancy. From this time up to puberty there is 
no period of special susceptibility. In two hundred and sixty-nine of the 
cases in Starr's collection, in which the nature of the tumour was stated, 
the following were the varieties : 

Tubercle 152 cases. 

Glioma 37 " 

Sarcoma 34 " 

Glio-sarcoma 5 " 

Cyst 30 " 

Carcinoma 10 " 

Gumma 1 " 

209 " 

Tuberculous tumours are more often multiple than are other varieties. 
Their most frequent seat is the cerebellum ; next to this the pons and 
crura cerebri. They are rarely cortical or central. Glioma is most often 
found in the cerebellum or in the pons, and next in the cortex ; but it is 
rarely central. Sarcoma is most frequently in the cerebellum ; next to 
this, in the order of frequency, in the pons, the basal ganglia, and the cor- 
tex. Cystic tumours are either central or cerebellar. Taking the cases 
as a whole, the most frequent seat of tumour in children is, first the cere- 
bellum, second the pons, third the centrum ovale. 

Tuberculous tumours are occasionally seen in infancy, but they occur 
most frequently between the ages of five and twelve years. They are 
usually secondary to tuberculosis elsewhere, especially in the lungs and in 
the bronchial lymph nodes. They most frequently start from the mem- 
branes, rarely being centrally situated, and extend inward, infiltrating 
the superficial portion of the cerebellum or cerebrum. There is almost 
invariably localized meningitis at the site of the tumour ; there may be 
adhesions between the dura and pia mater, and the disease may extend to 
the cranial bones. In size, these tumours vary from a small pea to a 
child's fist. They may be softened and broken down at the centre, or 
cheesy throughout. They are the result of a localized tuberculous in- 
flammation, which does not differ essentially from that seen in other 
parts of the body. 

Glioma is not infrequent in infancy. It is probably connected in 
every case with the ependyma of the ventricle. It repeats the structure 
of the neuroglia, being composed of connective tissue and branching cells. 



CEREBRAL TUMOUR. Y29 

Sarcoma may be of the spindle-celled or the mixed variety. It grows 
much more rapidly than glioma. The two varieties are not infrequently 
combined in the same tumour — glio-sarcoma. 

Cystic tumours are sometimes sarcomatous in origin, the wall of the 
cyst containing sarcoma cells, and they may also be parasitic, from the 
growth of the echinococcus. They may be found in any part of the brain. 

The other varieties of sarcoma, gumma and vascular tumours, are 
exceedingly rare until after puberty. 

As the tumour grows, secondary lesions are produced in most of the 
cases. These are the result of pressure upon arteries, causing localized 
anaemia, or even cerebral softening ; or upon veins, producing congestion 
and oedema. When affecting the middle lobe of the cerebellum, pressure 
upon the venae Galeni may lead to effusion into the ventricles. Localized 
meningitis over tumours superficially situated is the rule, and this may be 
the cause of some of the symptoms. Earely, cerebral haemorrhage may be 
associated. 

Etiology. — The causes of cerebral tumours are for the most part un- 
known. In a few instances there is a history of definite traumatism. 
Sarcoma or carcinoma may be secondary, and tuberculous tumours are 
probably always so. 

Symptoms. — These may be divided into two groups : first, the general 
symptoms which are common to tumours of all varieties, and are inde- 
pendent of location ; secondly, the local symptoms depending upon the 
situation of the growth. 

General symptoms. — One of the most frequent is headache. Though 
it varies much in its severity, character, and position, it is rarely absent. 
It is apt to be severe, and may continue for a long period, or it may be 
intermittent. The location of the pain has no definite relation to the 
situation of the tumour. It may be accompanied by sensations of tightness 
compression, or tension in the head. It may be associated with localized 
tenderness of the scalp ; when this is constant it is a valuable symptom 
for diagnosis, as it often occurs with tumours superficially located. 

General convulsions often occur in the early stage, but separated by 
quite long intervals ; they become more frequent and more severe as the 
disease progresses. All degrees of severity are seen, from slight twitchings 
and temporary loss of consciousness, to typical epileptiform seizures. They 
are most common when the growth is rapid and when complicating men- 
ingitis is present. Attacks of localized spasm may for a considerable time 
precede general convulsions; and in a single attack there may be first 
localized and then general convulsions. 

Mental symptoms are generally present in great variety and complexity. 
There may be only fretfulness and irritability, or a marked change in dis- 
position. These symptoms are so frequent from other causes in children 
that they excite no apprehension, unless to them are added dulness, 



730 DISEASES OF THE NERVOUS SYSTEM. 

apathy, and somnolence. Later in the disease there may be attacks of 
hypochondriasis, or of melancholia ; there may be periods of wild, almost 
maniacal excitement ; and, finally, the mental impairment may approach 
a condition of imbecility. 

Optic neuritis and optic-nerve atrophy are very frequent, occurring, 
according to Starr, in eighty per cent of the cases. This is only recog- 
nised by the ophthalmoscope, as there may be no disturbance of vision. 
The optic neuritis is generally double, appears earlier, and is more con- 
stant in basal tumours than in those at the convexity, or those centrally 
located. 

Vomiting is very frequent, but diagnostic only when it occurs sud- 
denly without assignable cause, and without nausea or other symptoms 
of indigestion. It is especially significant when frequently repeated, and 
of more importance in older children than in infants. 

Vertigo is often associated with vomiting. At first it is occasional and 
seen upon changing position, but later it may be quite constant, espe- 
cially with tumours in the posterior fossa. 

Disturbances of sleep are frequent. There is usually insomnia, but 
sleep may be broken by hallucinations, accompanied by attacks of scream- 
ing ; rarely is there persistent drowsiness until toward the end of the dis- 
ease. 

Local symptoms. — These depend upon the situation of the tumour, 
but not at all upon its anatomical character. Local symptoms may be 
wanting entirely, and they may vary much in different cases even with 
tumours in the same situation. They are modified by the size and by 
the rapidity of growth, and by the existence of local meningitis. 

In tumours of the cortex, the meninges are likely to be involved, espe- 
cially with tuberculous and gliomatous growths. The pathological process 
may extend from within outward or from without inward. The most 
frequent general symptoms in such cases are headache, circumscribed ten- 
derness of the scalp, convulsions, and mental symptoms. Optic neuritis, 
vomiting, and vertigo are not so common. Tumours situated in the fron- 
tal lobe, as a rule, present few symptoms and may be entirely latent. 
Irritation of the frontal lobe may extend to the motor area and cause 
convulsions either local or general ; but not often is there paralysis. Tu- 
mours of the left side (of the right side in left-handed persons) in the 
third frontal convolution may cause motor aphasia. 

Tumours in the motor convolutions along the fissure of Rolando pro- 
duce the most definite and uniform local symptoms. When situated at 
the upper portion the leg is affected, at the middle portion, the arm, 
and at the lower, the face. Irritative symptoms, such as rigidity or clonic 
spasm, commonly precede for some time the paralysis which results from 
pressure or destruction. These attacks of localized convulsions may begin 
in the face, arm, or leg ; but they usually extend more or less rapidly 



CEREBRAL TUMOUR. 731 

until all three are involved. There is no loss of consciousness, but there 
may follow a slight transient paralysis. Such attacks are known as " Jack- 
sonian epilepsy," and form one of the most diagnostic symptoms of cere- 
bral tumour. Localized spasm may be associated with anaesthesia or 
other disturbances of sensation. The paralysis generally first affects one 
extremity — the arm or leg, according to the location of the tumour — and 
afterward it may involve the entire side, including the face. 

If the tumour is centrally located, or at the base, hemiplegia may be an 
early symptom from pressure on the motor tract. With cortical paralysis 
there may be associated ataxia and anaesthesia. 

Tumours of the parietal lobe may give no local symptoms. At times 
there are disturbances of muscular sense, tactile sensibility, or sensations 
of pain and temperature. If the inferior parietal lobule of the left side 
is affected, there may be word-blindness, or inability to understand writ- 
ten language. 

Tumours of the occipital lobe produce, as the only constant local symp- 
tom, hemianopsia. This is usually bilateral, affecting the same side of 
both eyes, being on the side opposite to that of the lesion — i. e., a tumour 
on the right side causes blindness in the left half of both eyes, so that 
the patient sees nothing to the left of a line directly in front of him. 
Instead of hemianopsia, there may be only irritation and various disturb- 
ances of sight. 

Tumours of the temporo-sphenoidal lobe may be latent, or, if on the 
left side, may cause word-deafness — i. e., inability to understand the sig- 
nificance of spoken language. 

Tumours in the island of Reil when situated upon the left side (right 
side in left-handed persons) may cause motor aphasia or disturbances of 
speech. If they are large they may produce symptoms by pressure upon 
the motor tract, — hemiplegia or monoplegia. 

Tumours of the basal ganglia cause marked general symptoms, but 
none of a definitely local character. The important symptoms relate to the 
various tracts or bundles of fibres which pass from the cortex through the 
internal capsule. These include the motor and the various sensory tracts, 
the olfactory, auditory, visual, and speech tracts. Any of these may be 
pressed upon, and the nature of the symptoms will depend upon the size 
of the tumour and the extent of the pressure. If only the anterior part 
of the capsule is affected there may be no symptoms; if the middle 
fibres, hemiplegia and disturbances of articulation; if the posterior fibres, 
hemianaesthesia. All these may be associated, and any of them may be 
complete or partial. Tumours in this situation are apt to implicate the 
cranial nerves. Optic neuritis is quite constant, and appears early. Lo- 
calized or general convulsions are rare. 

The peculiar symptoms pointing to tumours of the crura cerebri are 
nystagmus, strabismus, and loss of pupillary reflex, sometimes with general 



732 DISEASES OF THE NERVOUS SYSTEM. 

muscular inco-ordination, and a' staggering gait. There is usually third- 
nerve paralysis on the side of the tumour, and on the side opposite to the 
hemiplegia with which it is often associated. This variety of crossed 
paralysis is quite diagnostic. The symptoms of third-nerve paralysis are 
external strabismus, dilatation of the pupil, and ptosis. In these cases 
optic neuritis appears early. There may be a complicating hydrocephalus. 
"While hemiplegia is commonly present with large tumours, it may be ab- 
sent with small ones, or may appear later than paralysis of the third nerve. 

Tumours of the pons are quite common. The diagnostic symptoms 
consist in crossed paralysis, the cranial nerve symptoms being on the side 
of the tumour, and the general motor and sensory symptoms on the oppo- 
site side. When the seat is the upper half of the pons, the third and fifth 
nerves are apt to be implicated, giving rise to ptosis, dilatation of the 
pupils, external strabismus, trophic disturbances such as ulceration of the 
cornea, and neuralgic pain in the face. Tumours in the lower half of the 
pons involve the sixth, seventh, and eighth nerves, causing internal strabis- 
mus, contracted pupils, facial paralysis, sometimes deafness, and auditory 
vertigo. Other symptoms associated with tumours of the pons are head- 
ache, vomiting, and optic neuritis ; convulsions being rare. 

Tumours of the medulla are recognised by the involvement of the 
glossopharyngeal, pneumogastric, spinal accessory, and hypoglossal nerves. 
There are difficulty of deglutition, irregular respiration, irregular pulse, 
and vaso-motor disturbances, such as flushing of the face and perspiration. 
There may be projectile vomiting, polyuria or glycosuria, opisthotonus, 
difficulty in articulation or in sucking, and in protrusion of the tongue. 
When large, these tumours may produce symptoms of pressure upon the 
motor or sensory tracts, — paralysis, partial anaesthesia, with rigidity and 
exaggerated reflexes. 

Tumours of the cerebellum are especially important this being the most 
frequent location in childhood. When only one hemisphere is affected 
there may be no local symptoms. Tumours involving the middle lobe, or 
those large enough to produce pressure upon the middle lobe, give rise to 
vertigo and cerebellar ataxia. Vertigo is especially frequent ; it may 
occur with headache. Cerebellar ataxia is different from the ataxia due 
to a spinal-cord lesion, and strikingly resembles that of intoxication. 
It may increase until the patient is unable to walk, although there is 
no loss of muscular power. Vomiting is a frequent symptom, as are also 
optic neuritis, and headache which is usually occipital. When there is 
secondary hydrocephalus, as is not uncommon, mental symptoms are 
present, and there may be enlargement of the head. Opisthotonus is 
occasionally seen, but general convulsions are rare. 

Diagnosis. — The size of the tumour is to be determined mainly by the 
general symptoms, special attention being given to the order of their 
development. A diagnosis as to the nature of the tumour is really not of 



CEREBRAL TUMOUR. 733 

much importance ; but some information upon this point may be gained 
from the consideration of its etiology, the rapidity of its growth, and the 
age of the patient. Cerebral tumour may be confounded with abscess, tuber- 
culous meningitis, chronic basilar meningitis, and chronic hydrocephalus. 
The symptoms distinguishing tumour from abscess are the following : Tu- 
mour may occur at any age ; without definite etiology, excepting when 
tuberculous ; the progress is steady, but generally slow, new symptoms be- 
ing continually added ; headache is more constant and more severe ; optic 
neuritis more frequent ; cranial nerves more often involved ; mental dis- 
turbances more marked ; focal symptoms are often definite ; fever is absent ; 
duration, six months to two years. As compared with the above, abscess 
is not so frequent, being especially rare in infancy ; there is a definite his- 
tory of traumatism or ear disease ; progress more irregular ; symptoms 
often intermittent ; headache less severe ; mental symptoms less marked ; 
optic neuritis and involvement of the cranial nerves less frequent ; focal 
symptoms usually indefinite ; localized tenderness over the scalp more 
constant ; fever present except in the latent period ; the most frequent 
complication is acute meningitis. 

Cases of tuberculous meningitis which may be confounded with tumour 
are those of slow course sometimes seen in older children. The diffi- 
culty in diagnosis is increased by the frequent association of tuberculous 
tumours with tuberculous meningitis. The main points of difference are 
that in tumour the symptoms are more localized and the course gen- 
erally much slower. Almost every individual symptom, however, may be 
present in the two conditions. 

Chronic basilar meningitis may produce symptoms almost identical 
with those of tumour in the posterior fossa. It is, however, confined to 
infancy, and is frequently syphilitic. Hydrocephalus and opisthotonus 
are much more marked than are usually seen with tumour. 

Chronic hydrocephalus may resemble tumour ; this occurs so frequently 
as a lesion secondary to tumour that the question often arises whether there 
is only hydrocephalus, or there is in addition a tumour. Primary hydro- 
cephalus is usually congenital, and the symptoms appear during the first 
year. It commonly attains to a greater degree than is seen in secondary 
hydrocephalus ; but the symptoms in the two forms may be identical. 

Prognosis. — The prognosis in cerebral tumour is absolutely bad ; ex- 
cept in syphilitic esses, wbicb are among the rarest forms seen in child- 
hood, there is no prospect of recovery, and hut little of improvement. 
The symptoms usually progress steadily from had to worse, and more 
rapidly in children than in adults. Death occurs from exhaustion, coma, 
convulsions, or from respiratory failure, sometimes suddenly from un- 
known causes. 

Treatment. — If there is any reason to suspect syphilis, the iodide of 
potassium should be given in large doses and continued for a long period ; 



734 DISEASES OF THE NERVOUS SYSTEM. 

the effect of this drug even in tumours not syphilitic is sometimes bene- 
ficial. Starr refers to a case in which symptoms of six months' duration, 
including optic neuritis, entirely disappeared under the use of mercury 
and the iodide. The tumour was supposed to be gumma, but an autopsy 
obtained six months later showed it to be a sarcomatous cyst. For a 
discussion upon the surgical aspect of the treatment of brain tumours, the 
reader is referred to Starr's work on Brain Surgery. 

HYDROCEPHALUS. 

Hydrocephalus or " water on the brain," consists in an accumulation of 
serum in the cranial cavity. This may be between the dura mater and 
the pia (external hydrocephalus) or in the ventricles of the brain (internal 
hydrocephalus). The former is secondary and is quite rare, while the lat- 
ter is not uncommon. Hydrocephalus may be acute or chronic. 

Acute Hydrocephalus is secondary to basilar meningitis, which is usu- 
ally of tuberculous origin. The terms tuberculous meningitis and acute 
hydrocephalus are sometimes used synonymously. A moderate distention 
of the ventricles is frequent in all varieties of acute meningitis. The 
amount of fluid in acute hydrocephalus is not great, there being rarely 
more than three or four ounces present. 

Chronic External Hydrocephalus is extremely rare, and is probably 
always a secondary lesion. It is found with certain congenital malforma- 
tions and with atrophy of the brain, and it may follow meningeal haemor- 
rhage or pachymeningitis. On incising the dura mater a few ounces, or 
sometimes even a pint, of serum may escape. The convolutions are some- 
what flattened, and may be greatly atrophied. Other lesions are found 
either in the brain or in the dura mater. There may be some degree 
of internal hydrocephalus associated. External hydrocephalus may cause 
enlargement of the head and separation of the sutures, and in fact most 
of the symptoms of the internal variety; but usually it is not severe 
enough to give rise to any decided symptoms. It is so rare that it need 
not be considered at length. 

CHRONIC INTERNAL HYDROCEPHALUS. 

This is the important variety, and when no qualifying term is men- 
tioned this is the form of hydrocephalus which is always understood. 

Etiology. — This occurs both as a primary and a secondary condition. 
When secondary it is usually associated with tumours of the base of the 
brain or with chronic basilar meningitis, either simple or tuberculous. It 
is in these cases a mechanical condition caused by pressure which oblit- 
erates the openings from the lateral ventricles into the fourth ventricle, 
or the foramen of Magendie. 

The causes of primary hydrocephalus are as yet very little understood. 
In a large proportion of the cases the disease is congenital, generally 



CHRONIC INTERNAL HYDROCEPHALUS. f35 

beginning in the latter months of intra-uterine life. Some of these cases 
are clearly syphilitic. D'Astros * has collected nine cases and added 
three others, in which hydrocephalus was associated with lesions un- 
doubtedly syphilitic. When due to syphilis, the disease may at the same 
time be congenital. Eickets and hydrocephalus are occasionally associ- 
ated, but so infrequently as to make a definite etiological connection be- 
tween them very doubtful. The rachitic head has been so often mistaken 
for hydrocephalus that an erroneous notion has arisen as to the frequent 
association of these two diseases. This point will be referred to more 
fully under diagnosis. Chronic hydrocephalus is often attributed to 
tuberculosis, but here again the connection is a very doubtful one. 
Heredity is a factor of some importance ; numerous instances are on 
record where two children in the same family have been affected. Hydro- 
cephalus not infrequently develops after successful operations upon spina 
bifida or encephalocele. 

Lesions. — The difference between the primary and secondary cases is 
chiefly one of degree. The amount of fluid in secondary cases is rarely 
more than three or four ounces. In primary cases it is usually from half 
a pint to one pint, but it may be very great. In one of my own cases 
there was removed from the head of a child, who died at four months, five 
pints of fluid. Larger quantities than this have been reported, but not at 
so early an age. In composition this resembles the cerebro-spinal fluid. 
An examination in one of my cases showed it to be a clear, translucent 
fluid, slightly alkaline in reaction, specific gravity 1005, containing sodium 
and potassium chlorides, alkaline phosphates, and a trace of albumin. In 
some specimens sugar is found. In cases of inflammatory origin the 
amount of albumin is generally larger, and the fluid may be slightly tur- 
bid. The effusion may become purulent from accidental infection re- 
sulting from operation, from 'rupture, or, as in one of my cases, from in- 
fection through the sac of a spina bifida with which it was complicated, 
the process extending to the brain through the central canal of the cord. 

The changes in the brain result from the gradual accumulation of 
fluid in the ventricles. The septum lucidum is usually broken down, 
and all the avenues of communication between the ventricular cavities 
are greatly enlarged. The continuous distention results in a gradual 
thinning of the brain substance which forms the. ventricular walls; often 
these are found only one fourth of an inch in thickness, or even less 
than this, the cortex being a mere shell (Fig. 117). In one of my 
autopsies the ependyma of the ventricle and the pia mater were in 
places actually in contact, all of the brain tissue having been absorbed ; 
the brain resembled a large double cyst. In a case of Peterson's, with 
the exception of a small portion of one temporo-sphenoidal lobe, all 



* Revue Mensuelle dea Maladies de L'Enfance. be, 481, 548. 



736 



DISEASES OF THE NERVOUS SYSTEM. 



of both hemispheres had disappeared, the cerebellum and basal ganglia 
alone being intact. The brain is always anaemic, and the gray and white 
substance may be indistinguishable. The changes are largely mechanical, 
the microscope showing, in my case just referred to, only granular matter 
and round nuclei evidently from broken-down nerve cells. In less severe 
cases the changes may be slight. It is, however, always surprising to see 
the amount of compression which the cortex will tolerate without inter- 
ference with its functions, provided the pressure comes gradually. The 
ependyma may be normal, but it is usually somewhat thickened and pale, 
sometimes granular, and may be infiltrated with new cells. When infection 
takes place an acute ependymitis may be set up. Chronic inflammation 

of the ependyma is thought 
to be the essential lesion in 
many of the primary cases, 
whether of simple or syphi- 
litic origin. 

The bones of the skull are 
markedly affected ; the su- 
tures at the vault are widely 
separated, and sometimes 
even those at the base. After 
the removal of the fluid the 
head collapses, giving an ap- 
pearance which has been well 
likened to a bag of bones. 
It should not be forgotten, 
however, that hydrocephalus 
may coexist with premature 
ossification, in which case the 
head may be small. In the 
cases w r hich recover, the wide 
gaps in the skull may be closed by the development of wormian bones ; but 
ossification is often not complete until the fifth or sixth year. 

The most frequent lesion associated with congenital hydrocephalus is 
spina bifida, in which cases there may also be a patency of the central 
canal of the spinal cord ; more rarely meningocele or encephalocele are met 
with. Sometimes there are deformities in other parts of the body, such as 
club-foot or hare-lip. 

Symptoms. — Hydrocephalus may exist with a small head. In this 
condition there is usually premature ossification of the cranial bones. 
Three such cases have come under my notice, one child having lived to 
be fourteen months old. These children are usually idiotic, and die at an 
early age, often from convulsions. In such cases other malformations of 
the brain are frequently associated. 




Fig. 117. — Vertical transverse section of a brain in con- 
genital hydrocephalus, from a child who died at the 
age of three weeks. A, distended lateral ventricle ; 
£, its descending horn. 



CHRONIC INTERNAL HYDROCEPHALUS. 



T37 



Hydrocephalus, with the exceptions mentioned, is recognised by the 
increased size of the head. In order to estimate the amount of enlarge- 
ment, it must be remembered that at birth the circumference of the 
normal head is about 14 inches, and at one year from 18 to 19 inches. 
The degree of enlargement in hydrocephalus may be very great. In one 
of my cases, the head at four months measured 24-|- inches. In another at 
ten and a half months, 26f inches (Fig. 118). Steiner has reported a re- 







Fig. 118. — Chronic hydrocephalus of a Bevere type; head of a globular shape : child, ten 

and a half months old. 



markable case in which the head at eight months measured 32| inches. 
When the enlargement of the head is not great the diagnosis is not so 
easy. Hydrocephalic enlargement is commonly symmetrical and in all 
directions. The head is sometimes globular in outline (Fig. L18) and 
sometimes pyramidal (Fig. 119). The forehead is exceedingly high and 
projecting, and there is a prominence at the root of the nose seen in no 
other form of enlargement. The sutures may be separated from half an 
inch to two or three inches ; the fontanel is very large, tense, and bulging; 
56 



738 



DISEASES OP THE NERVOUS SYSTEM. 



the veins of the scalp are enlarged and prominent. In marked cases 
fluctuation may be readily obtained, and the head may even be distinctly 
translucent. 

In the acquired form all these symptoms are less marked, and if ossi- 
fication of the skull has taken place it is often impossible to discover 
any increase in size. The rate of growth of the head varies much in dif- 
ferent cases, and it is the surest measure of the progress of the case. The 
increase in circumference is usually from one to three inches a month. 

The primary cases are for the most part of congenital origin, and the 
child may die in liter o. At other times the process may have advanced so 




Fig. 119. — Chronic hydrocephalus of average severity ; head of pyramidal shape ; showing char- 
acteristic expression of the eyes. 

far before birth that puncture of the head is necessary before delivery is 
possible. In perhaps the majority of cases no symptoms are observed at 
birth, or the head is only slightly larger than normal. Usually nothing 
is noticed until the child is two or three months old, when it is discov- 
ered that the head is increasing in size at an abnormal rate. If the 
progress is rapid, other symptoms are soon evident : the infant can not 
hold up its head ; it is lethargic, and all its perceptions are dulled, sight 
and hearing included ; there may be a general flaccid condition of all the 



CHRONIC INTERNAL HYDROCEPHALUS. 739 

muscles of the extremities due to a slight general paresis, but more often 
there is rigidity, which is usually most marked in the legs, but sometimes 
in the arms ; the hands are often clinched, with the thumbs adducted ; 
the reflexes are exaggerated ; the pupils are generally contracted and 
equal, though they may be dilated ; nystagmus and convergent strabismus 
are often present. Convulsions may occur from time to time, or may be 
deferred until near the close of the disease. As the head enlarges the 
body usually wastes, and the disproportion between the two may seem 
greater than it really is. 

Such congenital cases rarely see the end of the first year, and are often 
fatal during the first six months. The causes of death are marasmus, con- 
vulsions, and intercurrent disease, rarely rupture of the head. 

In the cases which develop more slowly, the symptoms are quite differ- 
ent. The head may not attain at eighteen months the size reached in the 
other cases at the third or fourth month. The surprising thing about many 
of these cases is that the distinctly cerebral symptoms are so few. Where 
the pressure develops gradually, the brain seems able to tolerate an almost 
indefinite amount of it, The more readily the bones of the skull yield to 
pressure the fewer are the nervous symptoms ; hence, other things being 
equal, they are less marked where the disease begins before the sutures 
are firmly ossified than in the later cases. A comparatively small amount 
of effusion may cause very marked symptoms in a child two or three years 
old, while a much larger amount in an infant of a year, may produce much 
less disturbance. It is for this reason that secondary hydrocephalus 
causes such striking symptoms, although the accumulation of fluid is 
small. 

Whether the progress of these cases is slow or rapid, the development 
of the child is greatly retarded. Many are not able to support the head 
until two or three years old ; frequently they do not walk until five or six 
years old. The special senses are generally not noticeably affected, but in- 
telligence in most cases is interfered with, — in some only slightly, in others 
very markedly, while some are idiotic. Contractions of the extremities 
are occasionally seen, but usually more of the hands than the legs. Sen- 
sation is not often affected. The course is a very chronic one. From 
time to time there are exacerbations of the symptoms, and even inter- 
current meningitis may be excited. 

Prognosis. — Recovery is rare. It is quite exceptional that a hydro- 
cephalic child reaches the age of seven years. In some eases the process 
goes on up to a Certain age and then Ceases spontaneously, and tlif child 
may go through life with a head very much larger than normal, usually 
with a mental condition somewhat impaired. Retrogression of the symp- 
toms is, however, never to be looked for. 

Diagnosis. — The most important symptom is the enlargemenl of the 
head, and this can only be arrived at by careful measuremenl and com- 



740 DISEASES OF THE NERVOUS SYSTEM. 

parison with the normal size. The rapidity of growth is quite as impor- 
tant for diagnosis as the fact of enlargement. If the head grows more 
than an inch a month there can be little doubt. Hydrocephalus without 
enlargement of the head can not be diagnosticated. The enlargement 
most frequently confounded with hydrocephalus is that which occurs in 
rickets. In the latter disease it is almost invariably irregular ; there are 
prominences over the two frontal eminences and over the parietal bones, 
often with furrows between them ; the enlargement of the head is due to 
thickening of the bones of the skull ; the marked prominence of the fore- 
head is not seen, and the increase in bi-parietal diameter is not present ; 
furthermore, there are other signs of rickets. 

Treatment. — Almost every sort of local treatment has been adopted for 
hydrocephalus, including incision, aspiration, cranial puncture with the 
trocar, lumbar puncture, blisters, strapping, and counter-irritation. Up 
to the present time there does not exist sufficient evidence to show that 
any one of these means is curative. If aspiration is done, the fluid reac- 
cumulates very quickly, while incision or cranial puncture is almost cer- 
tain to be followed by meningitis. If there is any reasonable suspicion of 
syphilis, mercurial inunctions to the head should be employed, and even 
in other cases a few favourable results have been reported. Convulsions 
and other functional symptoms are to be treated upon general principles, 
as they arise. At the present time I believe it is better to refrain from 
all operative measures unless rupture seems likely to occur. 



INFANTILE CEREBRAL PARALYSIS. 

Synonyms : Spastic diplegia, paraplegia, or hemiplegia. 

Under the term cerebral paralysis are included several groups of cases 
with causes quite dissimilar, but having certain definite clinical features 
in common. While the symptomatology is quite clear, there are many 
questions relating to the pathology that are not yet fully settled, although 
much has been added to our knowledge within the last few years. Paraly- 
sis depending upon cerebral tumour, abscess, or hydrocephalus is not in- 
cluded in this chapter. 

The cases of cerebral paralysis may be divided into three groups, 
according as the paralysis depends upon conditions existing prior to 
birth, upon those connected with birth, or upon those of subsequent 
development. 

I. Paralysis of Intra-TJterine Origin. — This is the least frequent con- 
dition. In such cases there is some congenital defect in the brain, due 
sometimes to arrested development, at others to such intra-uterine lesions 
as haemorrhage or thrombosis. There may be porencephalus, or cysts ex- 
tending deeply into the substance of the brain, sometimes communicating 



INFANTILE CEREBRAL PARALYSIS. 741 

with the ventricles. The origin of this condition is for the most part un- 
known. In rare cases the paralysis is due to cortical agenesis,* a condition 
in which the brain may seem normal to the naked eye, but the microscope 
shows a complete arrest in the development of the cells of the cortex, usu- 
ally affecting both hemispheres. In still other cases there are found gross 
defects in development in the motor centres of the cortex. Such a lesion 
is shown in Fig. 124, page 751. Cases in which there is conclusive evi- 
dence of intra-uterine haemorrhage are very rare. 

Symptoms. — In most of the paralyses due to intra-uterine lesions, loss 
of power is only one of the symptoms, and usually not the most promi- 
nent. It is rare that there is not some mental impairment, and usually 
idiocy is present. The type of paralysis is nearly always diplegic or para- 
plegic. Where this is due to arrested cortical development, a general flac- 
cidity of the muscles may be seen instead of the rigidity so characteristic 
of the other forms of cerebral paralysis. 

II. Birth-Paralysis. — Cerebral birth-paralysis is due in nearly all cases 
to meningeal haemorrhage. The primary lesions and the early symptoms 
have already been described (page 105) in connection with the Diseases of 
the Newly-Born. The secondary lesions present considerable variety. 
There may be found (1) meningo-encephalitis, (2) atrophy and sclerosis 
of the cortex, (3) cysts upon the surface, (4) secondary degenerations in 
the spinal cord. 

1. Meningo-encephalitis. — This lesion is often quite diffuse. There 
is thickening of the pia mater, and it is usually adherent to the brain 
substance. The cortex is involved to a variable degree, depending some- 
what upon the time which elapses between the initial lesion and the au- 
topsy. The following were the microscopical changes found by Sachs f in 
the brain of a child in my wards at the Babies' Hospital, who died at the 
age of one year of measles : The lesions were found everywhere in the 
cortex. The pia was universally adherent, and showed general cellular 
infiltration; its blood-vessels showed marked cellular proliferation, and 
the veins in the sub-pial space were dilated and filled with blood. In the 
pia dipping in between the convolutions similar changes were present. In 
the cortex few if any normal pyramidal cells were found, but in the outer 
layers were an enormous number of small glia cells. Many of the 
blood-vessels showed a cell-proliferation of fcheir walls. There was also 



* For fuller description, see Sachs's Nervous Diseases of Children, 1895, p. 601. 

f The clinical features of this case are quite as interest i 1 1 -_r as i he pal hological find- 
ings. The child was a first-born, delivered after a dry labour of forty-eight hours. 
It was asphyxiated, and from the first days of its life it had attacks of convulsions, 
usually repeated many times a day. During one of these convulsiohs the photograph 
from which Pig. 122 was made was taken by I>r. Peterson. The child had the symp- 
toms of typical spastic paraplegia— the arms being, however, slightly involved— retarded 
mental development, and convergent strabismus. 



742 DISEASES OF THE NERVOUS SYSTEM. 

a degeneration in the pyramidal tracts of the anterior columns of tire 
cord. 

2. Atrophy and sclerosis. — These changes vary much in extent and 
degree. There may be only a circumscribed area in which the convolu- 
tions are small, firmer than usual, and covered with an adherent pia, or 
there may be an atrophy so extensive as to involve a large part of one hemi- 
sphere (Figs. 120 and 121), or sometimes of both hemispheres. Usually 
the lesion is somewhat diffuse over the convexity of both sides, and much 
more frequently of the anterior than of the posterior half of the brain. 




Fig. 120. — Extensive atrophy and sclerosis of the right hemisphere, from an infant seven and a 
half months old ; probably the result of a meningeal hsemorrhage at birth (lateral view). 

History. — Twelve hours after birth was seized with general convulsions, which continued 
for three days. No other symptoms noticed till one mouth before death, when weakness of left 
arm was observed. Never held head erect. Was plump and well nourished ; died from erysipelas. 

Autopsy. — Pia not adherent; a large cyst occupied the region of the occipital and posterior 
part of the parietal lobes, showing in its floor discolouration and pigmentation, evidently from 
an old hsemorrhage. Eight optic nerve, tract, and crus much smaller than the left. 

"Where a depression of the brain exists the space is filled with cerebro- 
spinal fluid, and in many cases there is a deformity of the skull. 

3. Cysts upon the surface may occur alone or in connection with the 
lesions just mentioned. These are usually small, about the size of a wal- 
nut, but they may cover a large part of a hemisphere. Such large cysts 
are sometimes classed as cases of external hydrocephalus. 

4. Secondary degenerations of the internal capsule and the lateral col- 
umns of the cord are found in most of the cases associated with extensive 
atrophy and sclerosis, and in many of those in which only meningo- 
encephalitis is present. 

Symptoms. — The type of paralysis will of course depend upon the 
extent and position of the original lesion. A diffuse lesion is followed by 
diplegia ; one not quite so extensive by paraplegia ; one affecting one side 
only by hemiplegia, or even monoplegia, though this is very rare. The 



INFANTILE CEREBRAL PARALYSIS. 



743 



relative frequency of the different forms will vary according to the age at 
which the patients come under observation. Thus in the statistics of 
Sachs and Peterson,* there were twenty-seven cases of diplegia or para- 
plegia, and twenty-two of hemiplegia. These cases were drawn from 
miscellaneous sources, chiefly from a general neurological clinic. Ac- 
cording to my own observations, which have been chiefly upon infants, 




Fig. 121. — Atrophy of right hemisp] 



the cases of diplegia and paraplegia have outnumbered those of hemi- 
plegia more than four to one. My belief is that the greal majority of 
the congenital cases, or those due to haemorrhage occurring at birth, arc 
diplegias or paraplegias, and that very many of them succumb during the 
first two years, and never come under the observation of the neurologist; 
however, the cases of hemiplegia, because of the less serious lesion, live much 
longer, and hence are more likely to be Been by the specialist. Diplegia 



♦Journal of Nervous and Mental Disease, May, 1890. 



744 DISEASES OF THE NERVOUS SYSTEM. 

and paraplegia will therefore be considered as the characteristic types of 
cerebral birth-palsy, as the cases of hemiplegia do not differ from those 
due to later causes — i. e., the acquired form. 

In the most severe cases that survive the symptoms of the early 
days of life (page 107) there remains some rigidity of the extremities, 
chiefly of the legs, which is constant or intermittent, slight or well marked. 
There is often spasm of the muscles of the neck and trunk, giving rise to 
opisthotonus. In many cases there are frequent attacks of convulsions. 
(Fig. 122). The general physical development of the child is often inter- 
fered with, so that it remains small and delicate, and perhaps dies of some 
acute disease in early infancy, never having been able to sit erect, or even 
support its head. In other cases the general nutrition is not affected, 



1 ' \ 






jP 



Fig. 122. — Convulsions in spastic paraplegia; from a photograph by Dr. Frederick Peterson 
during an attack. (History on page 743.) 

and the infants may be plump and well nourished. Such children may 
live indefinitely. There is always some degree of mental impairment ; it. 
may be so slight as not to be noticeable until the child is old enough to 
talk, and sometimes not until the age of four or five years ; or the 'child 
may be idiotic. Speech is not only delayed, but is very imperfect. Hear- 
ing is frequently affected, but sight rarely. Often these children are not 
able to walk alone until they are four or five years old, and then with a 
peculiar cross-legged gait, owing to spasm of the adductors of the thighs. 
This may be so great as to entirely prevent walking, and while sitting or 
lying the thighs may cross each other. All the reflexes are greatly exag- 
gerated. In one child under my observation the pharyngeal reflex was so 
much increased that swallowing of solid food was impossible, owing to 
spasm of the muscles. Alcoholic stimulants and medicines that were at 



INFANTILE CEREBRAL PARALYSIS. 745 

all pungent were taken only with the greatest difficulty. In some of the 
worst cases walking is impossible, owing to the shortened tendons and 
the contractures which have occurred in the muscles. The arms are in 
nearly all cases much less affected than the legs, and in about half the 
number, according to the observations of Sachs, they are not involved at 
all. The condition is not incompatible with long life. 

In the mild cases it not infrequently happens that the early symp- 
toms are so slight as to be overlooked, and nothing excites suspicion until 
the infant is six or eight months old. There is then discovered an unmis- 
takable muscular weakness, as the child can not sit up, or even hold up the 
head when the trunk is supported. In most of the cases there is observed 
before this time a tendency to* stiffen the body and to throw it backward, 
owing to spasm of the cervical or spinal muscles. This may be slight, or 
it may be very marked. The muscular weakness is not infrequently mis- 
taken for rickets, and is sometimes regarded as simple backwardness. A 
closer examination usually discloses the presence of some rigidity of the 
extremities, particularly of the legs, and exaggeration of the knee-jerk. 
As the child grows older the other symptoms of late or imperfect develop- 
ment become more and more evident. 

There are changes in the shape of the skull, this being usually smaller 
than normal in all its diameters, or there may be asymmetry. There is 
an arrest of development in the paralyzed limbs. These are both smaller 
and shorter than normal. There is marked muscular atrophy. In many 
cases abnormal movements are seen, which may be of an irregular choreic 
type, or they may be athetoid. According to various statistics, epilepsy 
develops in from 33 to 50 per cent of all the patients affected. 

III. Acute Acquired Paralysis. — This is usually of the hemiplegic 
type, although diplegia and paraplegia may in rare instances be met with. 
This group includes cases developing at any time after birth, but the great 
majority of those seen in childhood, begin before the fifth year. 

Etiology. — The etiology of many of these cases is very obscure. The 
paralysis sometimes follows traumatism. It is occasionally seen in the 
course of scarlet fever, measles, diphtheria, variola, and pneumonia. 
Much more frequently than with any of these diseases it occurs during 
pertussis, being usually the outcome of a severe paroxysm. Aside from 
the traumatic cases and those occurring with pertussis (and these include 
but a small proportion), the real cause is for the most pari unknown. 
The frequency with which these cases are ushered in with convulsions has 
led many to assign this as the cause of the paralysis. It is more probable 
that the convulsions are the result than the cause of the lesion producing 
the paralysis. 

Lesions. — The lesions of acute cerebral palsy may he grouped under 
three heads: (1) those of the blood-vessels; (:l) those of the membra 
(3) those of the brain substance. 



746 DISEASES OF THE NERVOUS SYSTEM. 

1. Lesions of the blood-vessels. — There may be either haemorrhage, em- 
bolism, or thrombosis. Haemorrhage is by far the most important. It is 
usually meningeal, very rarely cerebral. It occurs more frequently at the 
convexity than at the base, and is often quite diffuse. Meningeal haemor- 
rhage may result from pachymeningitis. I have elsewhere stated my 
conviction that this is more frequent than is generally supposed. It may 
be due to traumatism, where it is also from the dura mater ; or from 
the acute hyperaemia accompanying paroxysms of pertussis, where it may 
be from the dura or the pia ; or it may be secondary to thrombosis of the 
superior longitudinal sinus. The association of haemorrhage with sinus- 
thrombosis is not very infrequent. It was found in one of my autopsies 
upon a patient who died of pneumonia. The bleeding in these cases is 
usually from the pia. Cerebral haemorrhage is extremely rare, but it 
occurs even in infants ; I once saw it in one only two months old. 

Embolism is rarely found unless associated with acute rheumatic endo- 
carditis, and then usually in children who are over seven years old. As 
in adults, the usual seat of the embolus is a branch of the middle cere- 
bral artery. It may be single or multiple. Thrombosis has been met with 
in a small number of cases, but it is extremely rare. 

2. Lesions of the membranes. — These are generally the result of old 
cerebro-spinal meningitis ; sometimes they may be of syphilitic origin. In 
both, however, the process is rarely confined to the membranes ; it is a 
meningo-encephalitis. 

3. Lesions of the brain substance. — Atrophy and sclerosis are terminal 
conditions found in a large number of the autopsies made upon cases 
where the paralysis has been of long standing. They vary in severity 
and extent, and are followed by secondary degeneration in the cord, as in 
cases of birth paralysis. There may be the same development of cysts of 
the pia mater, or an accumulation of fluid in the arachnoid cavity, these 
taking the place of the atrophied convolutions. What the primary lesion 
is in these cases is still a matter of debate. Strumpell believes many of 
them to be due to an acute porencephalitis, analogous to acute poliomy- 
elitis. Cases are not infrequently seen clinically, which this pathology 
seems to explain very satisfactorily. However, there is as yet lacking suffi- 
cient anatomical evidence to establish this view. 

In this connection may be mentioned a case of acute paralysis in 
which no lesion was found. In the spring of 1894, there was admitted to 
my service in the Babies' Hospital, an infant with pneumonia, who had 
developed, a few days before, typical right hemiplegia. The pneumonia 
antedated the paralysis by several days. The latter came on suddenly, 
with convulsions, and involved the face, arm, and leg. The arm and leg 
appeared to be completely paralyzed, but in the face the paralysis was 
incomplete. The paralysis had begun to improve somewhat at the time 
of the child's death, which occurred a little over a week after its onset. 



INFANTILE CEREBRAL PARALYSIS. 747 

At the autopsy no gross lesion could be discovered. A careful microscop- 
ical examination was made by two expert pathologists, Drs. C. A. Herter 
and J. S. Thacher, who could find no explanation of the paralysis. Noth- 
ing abnormal was found except " a slight increase of small spheroidal cells 
about some of the meningeal and cortical vessels of the motor area. The 
frontal and occipital lobes were normal." 

Symptoms. — While diplegia and paraplegia are occasionally seen, the 
great majority of cases of acquired cerebral palsy are of the hemiplegic 
variety. When diplegia and paraplegia occur, it is usually in early in- 
fancy, and their symptoms and course differ in no wise from the birth- 
palsies. We may therefore regard hemiplegia as the chief manifestation 
of acquired cerebral palsy. 

The onset of the paralysis is almost invariably sudden, with convul- 
sions, which are usually repeated, and in severe cases followed by loss of 
consciousness. In the secondary cases these are generally the only symp- 
toms. In one of my cases the patient went to bed apparently well, and 
awoke in the morning with hemiplegia. Such an onset, however, is very 
exceptional. When the paralysis is apparently primary, fever is usually 
present, and in addition to the convulsions there may be vomiting, de- 
lirium, and other symptoms, strongly suggestive of an acute inflammatory 
process in the brain, which continue for a variable time, usually two or three 
days, before paralysis is seen. The temperature in most cases is from 
100° to 102° ¥., and the rise of temperature follows more frequently than 
precedes the convulsions. After the child recovers consciousness, and 
sometimes before this, the paralysis is discovered. If there is a very ex- 
tensive lesion there may be diplegia, deep coma, and death, but this is 
very infrequent. Usually the lesion is more limited, and the symptoms 
are those of typical hemiplegia. It is rare that the face is much involved, 
and often it escapes altogether. The paralysis of the arm and leg is at 
first complete, but may improve very rapidly in the course of a few days. 
Disturbances of sensation are usually of a transient character. After a 
variable period, from one to several weeks, the patient begins to use the 
paralyzed extremities, the arm recovering more slowly than the leg, as in 
adult hemiplegia. The convulsions may be repeated for the first day or 
two, but prolonged or continuous convulsions are rare. With lesions of 
the left side of the brain, speech may be affected, and not infrequently 
in young children when the lesion is upon the right side. The reflexes 
are increased upon the affected side, and slight ankle-clonus may be present. 

In the course of a few weeks the child may be able to walk, dragging 
the affected leg ; the recovery in the leg is sometimes complete, lml in mosl 
cases a slight halt in the gait remains. The arm usually recovers more 
slowly than the leg, and contractures are likely to develop after a variable 
time, generally two or three years. In Fig. 123 is shown a frequenl de- 
formity of the upper extremity. Contractures of the leg lead to various 



748 



DISEASES OF THE NERVOUS SYSTEM. 



forms of talipes, generally equinus, from shortening of the tendo-Achillis. 
Sometimes the arm or the leg recovers so perfectly that the case may 

be regarded as one of monoplegia. In old 
cases the paralyzed limbs are atrophied; 
there is more or less rigidity, and the spas- 
tic condition may be quite marked. I have 
seen this limited to a single group of mus- 
cles in the leg. Aphasia is common in 
right hemiplegias, and it is not infrequent 
in those of the left side, because infants 
appear to use both sides of the brain with 
nearly equal facility. 

The mental condition of these children 
is usually normal, in striking contrast with 
the cases of congenital diplegia. The 
earlier the paralysis occurs the more likely 
are mental symptoms to be present, since 
we have here not only the direct effect of 
the lesion, but an arrested development of 
some part of the brain. Epilepsy is not 
an uncommon sequel ; it may be of the 
Jacksonian type, or there may be attacks 
of general convulsions. In other cases 
there are post-hemiplegic movements of a 
choreic or athetoid character, or irregular 
inco-ordinate movements. 

Prognosis of Infantile Cerebral Paraly- 
sis. — In diplegia and paraplegia the outlook 
is always unfavourable. A very large num- 
ber of these cases which are due either to 
intra-uterine or birth lesions, never reach 
the third year, but die in infancy of maras- 
mus or acute intercurrent disease. Those who survive usually show seri- 
ous mental defects, and many are practically helpless on account of the 
extreme spastic condition of the muscles of the extremities. 

In hemiplegia the prognosis is much more favourable. In most of 
these cases the paralysis is of the acute acquired variety, and the later the 
period of onset, the less likely is the brain to be seriously damaged. In 
some of these patients complete recovery takes place ; in others the residual 
paralysis is so slight as to be easily overlooked except on careful examina- 
tion, the occurrence of epilepsy being perhaps the first thing which leads 
one to suspect that a previous paralysis has existed. The great majority of 
children who have suffered from infantile cerebral palsy have some degree 
of permanent paralysis and 4 usually some deformities from contractures. 




Fig. 123.— Deformity of left hand the 
result of contractures following 
an attack of hemiplegia four 
years before ; child seven years 
old. 



INFANTILE CEREBRAL PARALYSIS. 749 

the extent of both varying, of course, with the severity of the primary 
lesion. In all cases seen in young infants it is exceedingly difficult to 
give a prognosis in regard to future mental development. As a rule, the 
impairment is directly proportionate to the extent of the paralysis and 
its intensity ; although in exceptional cases we find a good deal of men- 
tal disturbance with only moderate paralysis, and vice versa. 

Diagnosis. — The diagnosis between the congenital and acquired forms 
of cerebral palsy, is of no great practical importance, and it may be im- 
possible ; for the symptoms in congenital cases are often not sufficiently 
marked to attract attention until children are old enough to sit alone or 
to walk. 

It may be quite difficult to distinguish cerebral paralysis from infantile 
spinal paralysis. The history of an acute onset, the atrophied limbs, the 
deformities, and the absence of sensory disturbances, may be found in both 
conditions. Spinal paralysis is, as a rule, monoplegic, and often affects 
but a single group of muscles. Cerebral paralysis is either diplegic or 
hemiplegic in character, and even though only a leg or an arm may seem 
to be affected, a critical examination will usually reveal the fact that 
the other limb of that side has also suffered. The presence of rigidity and 
exaggerated reflexes is quite as important evidence of this as loss of power. 
The electrical reactions, however, are conclusive ; the reaction of degen- 
eration is absent in cerebral paralysis, while it is present in spinal paralysis. 

Simple as the differentiation may seem in most cases, the mistake is 
frequently made of confounding cerebral diplegia, particularly of the flac- 
cid type, with rickets. But a careful history and a thorough examina- 
tion will usually dispel all doubt (see pages 232, 233). Cases of acute 
acquired paralysis at the onset may be mistaken for acute meningitis, 
but early loss of consciousness, the early development of the paralysis, its 
permanent character, and the short duration of the acute symptoms, dis- 
tinguish cases of haemorrhage from those of meningitis; but when it fol- 
lows traumatism, and when it occurs in the course of some other dis- 
ease such as pneumonia or scarlet fever, it may be difficult or impossible 
to make a diagnosis between the two conditions. 

Treatment.— The course and the result of cerebral paralysis depend 
upon the extent of the injury to the brain, its nature, and the age at 
which it is inflicted, — all these being conditions which are beyond tin- 
power of the physician to modify or control. The treatment of cerebral 
palsy is therefore extremely unsatisfactory. For the congenital cases prac- 
tically nothing can be done, except for the deformities and complications. 
The acquired cases during the acute onset arc to be managed like all other 
cases of acute cerebral congestion or inflammation, -absolute rest, ice to 
the head, and bromides. Electricity is never to be \i-n\ in early cases, and 
little or nothing is to be expected from it in the lute ones. Much can be 
accomplished in an educational way for the mental derangements re- 



750 DISEASES OF THE NERVOUS SYSTEM. 

suiting from cerebral palsy ; this, however, belongs more properly to the 
subject of idiocy. 

An important part of the treatment relates to the deformities. Many 
of these may be prevented by the early use of orthopaedic apparatus. 
Serious deformities in old cases may be greatly benefited by tenotomy 
or myotomy, followed by the application of suitable apparatus. In fact, 
very little can be done for these patients except by the orthopaedic surgeon. 
Epilepsy is to be treated as in cases depending on other causes. 

FEEBLE-MINDEDNESS, IDIOCY, IMBECILITY. 

By these terms are designated the different forms of mental impair- 
ment, seen in children as a result either of arrested development or dis- 
ease of the brain. They differ in degree rather than in kind, and may be 
associated with a variety of pathological conditions. Following somewhat 
the classification of Ireland, these cases may be grouped as follows : 

1. Those depending upon the arrested development of the brain as a 
whole, or upon that of the frontal lobes. An excellent example of this 
class of cases is shown in Fig. 124. Another form is "agnesia corti- 
calis " (page 741). 

2. Those associated with hydrocephalus. 

3. Those associated with microcephalus, with or without premature 
ossification of the cranial bones. 

4. The paralytic cases, — including the varieties which occur in the dif- 
ferent forms of cerebral paralysis, the greater part of which are due to 
meningeal haemorrhage at the time of birth, and associated with spastic 
diplegia or paraplegia ; a smaller number are associated with acquired 
palsy, which is most frequently due to meningeal haemorrhage. 

5. Those of inflammatory origin. They follow cerebro-spinal men- 
ingitis, and possibly also there may be added a group dependent upon 
poliencephalitis (Strumpell). 

6. Those associated with epilepsy, in which the condition is a result of 
changes in the brain produced by the repetition of the epileptic seizures. 

7. Sporadic cretinism (page 752). 

Cases of mental impairment probably do not follow ordinary attacks 
of infantile convulsions or traumatism without some definite lesion of 
the brain, and hence have been included in some of the foregoing 
varieties. 

In addition to the etiological factors belonging to the separate con- 
ditions described, there are to be considered influences of heredity, 
nervous diseases in the family, alcoholism, syphilis, and some other in- 
herited vices of constitution in the parents, and intermarriage among 
blood relations. 

Most cases of idiocy exhibit to a greater or less degree, the stigmata 
of degeneration (page 757). In the examination of five hundred and 



FKEBLE-MINDBDNESS, IDIOCY, IMBECILITY. 



751 



seventeen idiots by Howe, there were found blindness in twenty-one ; deaf- 
ness in twelve ; some defect of the nose or mouth, such as hare-lip, high 




Fig. 124.— Arrested development of the frontal lobes of the brain, particularly of the right side, 
from an idiotic child twelve months old.* 



palatal arch, or cleft palate, in twenty-three cases ; and sonic deformity of 
the hands or feet in fifty-four cases; while in ninety-six there was pa- 
ralysis of one or more limbs. f 



*A microscopical examination by Dr. Martha Wollstein Bhowed thecortes in the 
affected region to be only one-third I he normal thickness; the cortical layers were ill- 
defined; there was a striking absence of the characteristic nerve cells, both the large 
and small pyramidal cells being few in number. There was no growth of connective 

tissue. The white substance was normal, as were also the dura and pia. 

f For the symptoms of idiocy in detail, reference is made to works on diseases of 
the nervous system, especially to the Monograph of Langdon Down, and to the article 
by Brush in Keating's Cyclopaedia, vol. i\\ p. 1019, in which will be found references to 
recent medical literature upon the subject. 



752 



DISEASES OP THE NERVOUS SYSTEM. 



SPORADIC CRETINISM. 



Synonyms : Cretinoid Idiocy ; Myxedematous Idiocy ; Idiocy with Pachydermatous 

Cachexia. 

Since the early description of this disease by Fagge, in 1871 and 1874, 
numerous cases have been published in England, on the continent of 
Europe, and in America, showing that the disease is not confined to any 
country. During the last six years, five cases have come under my own 
observation. While the disease is rare, cretins are much more common 
than was formerly supposed. 

Etiology. — It is now well established that this condition depends either 

upon a congenital absence of the 
thyroid gland, or something 
which abolishes its functions. 
In Bramwell's series of forty- 
four cases, ten autopsies are re- 
ported ; in nine of these no trace 
of the thyroid gland could be 
found, and in the tenth one lobe 
was the seat of a large tumour. 
The symptoms are practically 
identical with the myxcedema of 
adults which follows the removal 
of the thyroid gland. Regarding 
the causes which destroy the 
thyroid gland or abolish its func- 
tions little is as yet known. In 
most cases it is a congenital con- 
dition. In some instances it has 
followed acute disease. As a 
rule, only one case occurs in a 
family, the other members of 
which present nothing abnormal 
in mental or physical develop- 
ment. 

Symptoms.— The symptoms 
of cretinism in most cases make 
their appearance during the first year, sometimes not until children are 
two or three years old, and occasionally none may be seen until the seventh 
or eighth year. The general appearance of the cretin is very striking, and 
so characteristic that when once seen the disease can not fail to be recog- 
nised (Figs. 125 and 126). The body is greatly dwarfed, and children of 
fifteen years are often only two and a half or three feet in height. All 




Fig. 125. — A typical cretin, nine years old ; height, 
28i inches. (After Bramwell.) 



SPORADIC CRETINISM. 



753 




*c ;( 



m 







754 DISEASES OP THE NERVOUS SYSTEM. 

the extremities, the fingers and the toes, are short and stumpy. The 
subcutaneous tissue seems very thick and boggy, but does not pit upon 
pressure like ordinary oedema. The facies is extremely characteristic : 
The head seems large for the body, the fontanel is open until the eighth 
or tenth year, and it may not be closed even in adults ; the forehead is 
low and the base of the nose is broad, so that the eyes are wide apart ; the 
lips are thick, the mouth half open, and the tongue usually protrudes 
slightly; the cheeks are baggy, the hair coarse, straight, and generally 
light coloured. The teeth appear very late — in one of my cases none were 
present at two years — and are apt to decay early. 

Fatty tumours are quite constant in older children, although they were 
wanting in two of my infantile cases. They are seen in the supra-clavicu- 
lar region, just behind the sterno-mastoid muscle, sometimes in the axilla, 
or between the scapulae, and sometimes in other parts of the body. In 
distribution they are apt to be symmetrical, and are usually about the size 
of a hen's egg. The neck is short and thick. In some cases there is a 
depression corresponding to the location of the thyroid gland. The chest 
is not deformed. The abdomen is large, pendulous, and resembles that 
of rickets. The skin is dry, perspiration scanty, and eczema is common. 
The voice is hoarse and rough. Patients often do not walk until they 
are five or six years old, and then they waddle in a clumsy way. All the 
movements of the body are slow and lethargic, and everything indicates 
a mental and physical torpor. The rectal temperature is usually sub- 
normal. I had once an opportunity to observe an attack of acute broncho- 
pneumonia in one of these cretins two years old. The symptoms and 
physical signs were typical, but during the greater part of the disease 
the rectal temperature fluctuated between 95° and 98*5° F. Only once 
was a temperature above 99° F. recorded. On account of their low tem- 
perature and torpid condition these patients are very sensitive to cold. 
The mental condition is always impaired, and they are usually idiotic. 
Speech is acquired late, and in some cases not at all. Cretins are dull, 
placid, arid good-natured, rarely troublesome or excitable ; and when 
fifteen or eighteen years old they appear like children of two or three 
years. There is an absence of development of the sexual organs, and 
almost invariably they suffer from chronic constipation. 

Diagnosis. — The diagnosis is usually easy, although the early cases 
are sometimes miscalled rickets. The low temperature, the facial ex- 
pression, the torpor, and the fatty tumours are enough to differentiate 
the two diseases. 

Prognosis and Treatment. — There is no tendency to spontaneous 
improvement. Many of these cases die in childhood, but a few live 
to adult life. Until within the last few years they have been con- 
sidered hopeless. The improvement which followed the use of the 
thyreoid extract in cases of adult myxoedema has led to a trial of this 



INSANITY. 755 

remedy in sporadic cretinism. A sufficient number of cases have now 
been recorded to establish the fact that the thyroid extract is a specific 
remedy for this disease. Peterson and Bailey * have collected forty 
cases treated in this manner. No case failed to improve when the ex- 
tract was properly given. In twenty-five cases the improvement was 
very striking, and in several it was truly remarkable (Figs. 126, 127, 128). 
After a few months' treatment the entire appearance of the child is in 
most cases changed : The idiotic expression of the features is lost ; the 
thickening of the skin and subcutaneous tissues disappears; there is a 
marked increase in weight, and in the growth of the whole body; muscu- 
lar power is rapidly developed, so that many soon become able to walk ; 
and progress is seen in dentition, and in some older girls in the establish- 
ment of menstruation. Intellectual progress is much slower than phys- 
ical changes ; however, nearly all the children become brighter and more 
intelligent, and a few learn to talk. In none of the cases so far reported 
has treatment been continued longer than eighteen months, so that it is 
as yet impossible to say whether improvement will continue indefinitely, 
and whether complete recovery is to be expected. From present knowl- 
edge the latter seems very improbable. In all cases the thyreoid extract 
must be given indefinitely, for otherwise improvement ceases at once, and 
cases may even relapse. The earlier the treatment is begun the more 
marked is the improvement usually noticed. 

The preparation most used in America is Parke, Davis & Co.'s desic- 
cated extract, prepared from the thyroid gland of the sheep. Of this 
from one half to one grain is given twice a day. Some disturbances are 
often seen at the beginning of the treatment — perspiration, fretfulness, 
and sometimes a rise in temperature — but these soon pass off. In some 
cases a smaller dose must be used at first, and the increase made very 
gradually. 

INSANITY. 

Insanity is so special a subject, that all that will be attempted here will 
be to mention the most frequent varieties seen in early life, with the im- 
portant etiological factors which operate at this period. For a full dis- 
cussion of the subject the reader is referred to works upon insanity, and 
to Sachs, in whose book \ will be found quite a full bibliography of this 
branch of the subject. 

Insanity is distinguished from idiocy in that it affects a mind previ- 
ously sound, however, the two conditions may be associated. Undoubted 
cases of mental disease have been observed before the seventh year, hut 



* Paediatrics, May 1, 181)0. See also Osier, American Journal of the Medical Sci- 
ences, November, 1893; and Bramwell'a Monograph on Cretinism. 

f Nervous Diseases of Children, New York, 1895. See also Mills, in American Text- 
Book of Diseases of Children, edited by Starr, Philadelphia, L894 



756 DISEASES OF THE NERVOUS SYSTEM. 

they are extremely rare. From this time up to puberty, however, nearly 
all the varieties seen in adult life occasionally occur, but they are very in- 
frequent even at this period. The form which insanity in childhood most 
frequently assumes is mania. 

Etiology. — Insanity is sometimes seen as a sequel of one of the infec- 
tious diseases, more often typhoid fever than any other, although it may 
follow measles, scarlet fever, diphtheria, or variola. Another cause is 
masturbation, although its effect is much more frequently seen after 
puberty than before. Hereditary syphilis is sometimes the cause of de- 
mentia, which comes on about the fourth or fifth year, or even later. 
Alcoholism, epilepsy, insanity, or other nervous diseases in the parents 
are important causes. Prolonged or continuous mental strain, the result 
of overwork in school, is a cause of considerable importance, especially in 
girls about the time of puberty. As exciting causes may also be men- 
tioned various reflex conditions, such as intestinal worms, phimosis, delay 
in the establishment of menstruation, and abnormal conditions of the nose 
and throat ; these, however, can not have much influence except where the 
predisposition is a strong one. Insanity may be associated with or may 
follow hysteria, chorea, or epilepsy. It has sometimes followed injury to 
the brain, acute meningitis, and occasionally other forms of brain disease. 

Symptoms. — Certain forms of insanity are practically never seen in 
children, such as paranoia or primary delusional insanity, acute demen- 
tia, paretic dementia, periodic or circular insanity, and cataleptic insanity. 

Mania is one of the most frequent forms, and is the most common 
variety of post-febrile insanity. Its symptoms may be quite intense, but 
are usually of short duration, lasting but a few days or weeks. In rare 
cases it may continue for months, and it may even be permanent. 

Melancholia is not uncommon. It is seen as a result of prolonged 
mental strain in school, it may be due to fear of punishment, and some- 
times may follow masturbation. It is usually associated with some very 
marked disturbance of the general health. It shows itself, as in the adult, 
by fits of depression, self-mutilation, and even by suicidal tendencies. 

Epileptic insanity may follow epilepsy in children who were previously 
mentally sound, where it may take the form of true epileptic dementia, 
or there may be attacks of mania which occur in the place of an epileptic 
seizure or follow such a seizure. Transitory attacks of fury or frenzy 
coming on without apparent cause should always suggest the possibility 
of epilepsy. 

Other forms which insanity assumes in early life are : transitory psy- 
choses, such as delirium, night-terrors, attacks of sobbing or weeping, 
sometimes from fright ; moral insanity, as shown by perversion of the 
moral sense from injury or disease, and by various vicious tendencies; 
morbid impulses, which may be homicidal or sexual, or a disposition to 
thieving, lying, pyromania, etc. ; morbid fears, of which there may be an 



THE STIGMATA OF DEGENERATION. 757 

almost endless variety. These are sometimes associated with a low state 
of physical health ; this, however, is usually not the case. 

Prognosis. — On the whole, insanity in childhood has a better progno- 
sis than in the adult. In most of the cases of mania, melancholia, the 
various transitory psychoses, or the choreic and hysterical forms, recovery 
occurs with proper treatment. The outlook for the other varieties is 
much worse, especially in those in which there is a strong hereditary 
tendency to mental disease. 

The treatment is to be conducted along the same general lines as in 
adults. 

THE STIGMATA OF DEGENERATION. 

These marks are of much importance in relation to the different forms 
of nervous disease in children, especially epilepsy, idiocy, and insanit}\ 
They are of great value in determining existing nervous disease, or as 
showing latent neuropathic tendencies. 

The physician should be familiar with these various signs in order that 
he may connect them with each other and refer them to their proper 
source, and at the same time, by appreciating their significance, be able 
to advise parents with regard to the care, education, mode of life, and 
occupation of children, in whom to a greater or less degree these signs 
may be present. These stigmata are not of equal importance as marks of 
degeneration. Some of them, such as facial asymmetry and most of the 
deformities of the palate, are always to be so regarded ; the speech defects 
are often so, while many of the others may or may not be, according to 
their association. The stigmata are divided into anatomical, physiological, 
and psychical. The following is the classification given by Peterson : * 

Anatomical Stigmata.— Cranial anomalies : Facial asymmetry ; de- 
formities of the palate ; anomalies of the teeth, tongue, lips, or nose. 

Anomalies of the eye: Flecks on the iris; strabismus; chromatic 
asymmetry of the iris; narrow palpebral fissure; albinism; congenital 
cataract ; pigmentary retinitis. 

Anomalies of the ear. 

Anomalies of the limbs : Polydactyly; syndactyly; ectrodactyly ; Bym- 
elus ; phocomelus ; excessive length of the arms. 

Anomalies of the trunk: Eerniffl; malformation of the breasts and 
thorax; dwarfishness ; giantism; infantilism; femininism ; masculinism ; 
spina bifida. 

Anomalies of the genital organs. 

Anomalies of the skin : Polysarcia; hypertrichosis; absence of hair; 
premature grayness. 



* Deformities of the Bard Palate in Degenerates, by Frederick Peterson, M. D., 

International Dental Journal, December, 1895. 



758 DISEASES OF THE NERVOUS SYSTEM. 

Physiological Stigmata. — Anomalies of motor function : Walking late ; 
tics ; tremors ; nystagmus ; epilepsy. 

Anomalies of sensory function : Deaf-mutism ; neuralgia ; migraine ; 
hyperesthesia ; anaesthesia ; blindness ; myopia ; hypermetropia ; astig- 
matism ; Daltonism ; hemeralopia ; concentric limitation of the visual 
field. 

Anomalies of speech : Mutism ; defective speech ; stuttering ; stam- 
mering. 

Anomalies of genito-urinary function : Enuresis ; sexual irritability ; 
impotence ; sterility. 

Anomalies of the instinct or appetite : Merycism ; uncontrollable ap- 
petites for food, liquor, drugs, etc. 

Diminished resistance to external influences and diseases. 

Retardation of puberty. 

Psychical Stigmata. — Insanity; idiocy; imbecility; feeble-mindedness; 
eccentricity ; moral delinquency ; sexual perversion. 

DEAF-MUTISM. 

Excluding the cases in which idiocy is present, which are not con- 
sidered in this chapter, deaf-mutism may be due either to congenital or 
acquired conditions ; the larger proportion of the cases belong in the lat- 
ter class. When congenital, deaf-mutism may result from ostitis, or peri- 
ostitis of the temporal bone, encroaching upon the cavity of the middle 
ear, from anchylosis of the ossicles, from absence of the internal ear or 
any of its parts. There may also be colloid degeneration of the labyrinth. 
It may result from atrophy of the auditory nerve, and it may be due to a 
lesion of the brain. These congenital conditions are often hereditary. 
Acquired deaf-mutism is most frequently the result of scarlet fever, and 
is due to otitis. The second important cause is cerebro-spinal meningitis, 
where it may be due to a lesion of the brain, the auditory nerve, or the 
ear. It occasionally follows mumps, diphtheria, measles, and other infec- 
tious diseases. It may result from repeated attacks of acute otitis associ- 
ated with adenoid growths or chronic rhino-pharyngitis. 

The younger the child at the time the deafness occurs the sooner the 
power of speech is lost. In most of the infectious diseases, if the attack 
occurs before the fifth year speech is lost. According to Love,* total deaf- 
ness is rare among deaf-mutes ; hearing for speech is present to a useful 
degree in about twenty-five per cent of the cases, while hearing by cranial 
conduction exists in nearly all cases. Deaf-mutism should be suspected 
if a child not idiotic shows at the end of two years no signs of beginning 
to talk. A careful distinction should be made between deaf-mutism and 
idiocy resulting either from congenital conditions or acquired disease. 

* Deaf- Mutism, by James K. Love. Macmillan & Co., 1896. 



MALFORMATIONS OF THE SPINAL CORD. 759 

It is necessary that this condition be recognised as early as possible, in 
order that the child may have the advantages of proper training during 
its early years. The physician should insist upon the child being sent to 
an institution where it may be taught to speak as early as the third, and 
certainly by the fourth year. 

The treatment is mainly prophylactic. The most important relates to 
the care of the ears in scarlet fever, and the removal of adenoid vegeta- 
tions of the pharynx and other causes which produce attacks of acute or 
chronic otitis. For the condition itself education is the only thing to be 
considered. 



CHAPTER IV. 
DISEASES OF THE SPINAL CORD. 

MALFORMATIONS. 

Malformations of the cord are very frequently associated with those 
of the brain, and bear a certain degree of resemblance to them. (1) The 
cord may be absent (amyelia) ; this condition may exist alone or with ab- 
sence of the brain. (2) The lack of development may be only partial 
(atelomyelia), as where some of the tracts are wanting. The most impor- 
tant one is defective development of the lateral tracts, which may be a 
cause of spastic paraplegia (Charcot). (3) There may be a malposition of 
some of the gray matter (heterotopia). (4) There may be a double cord 
(diplomyelia) ; the division is generally incomplete, and is attributed to an 
abnormal development of the central canal ; it is usually associated with 
other deformities. All of these malformations are extremely rare and of 
very little practical interest. 

There remains to be mentioned the only one which is really impor- 
tant — spina bifida. 

Spina Bifida. — This is a malformation of the vertebral canal with a 
protrusion of some part of its contents in the form of a fluid tumour. The 
tumour is elastic, compressible, usually increased by crying, and sometimes 
by pressure upon the anterior fontanel. The contained fluid is clear serum, 
resembling in all respects the cerebro-spinal fluid. It is one of the most 
frequent congenital deformities. 

According to Humphrey, spina bifida is due to an early failure in 
development, — in most cases before the cord is segmentated from the epi- 
blastic layer from which it is developed. Hence it remains adherent to 
the epiblastic covering, and the structures which should be formed between 
the cord and the skin are undeveloped. For this reason we have in the 
wall of the sac a fusion of the elements of the cord, nerves, meninges, ver- 
tebral arches, muscles, and integument. If the error in development occurs 



760 



DISEASES OF THE NERVOUS SYSTEM. 




Fis. 129. — Meningo- 
cele (partially dia- 
grammatic). A, the 
membranes ; B, the 
spinal cord ; (7, the 
integument. The 
accumulation of 
fluid is behind the 
cord, which does 
not enter the sac. 



later, the cord and nerves may be attached to the sac, but not intimately 
fused with it ; in still other cases the cord does not enter the sac at all. 
The malformation may occur before the central canal 
is closed ; or, if closed, it may reopen from the accu- 
mulation of fluid. It is probable that the accumula- 
tion of fluid first occurs, and that this prevents the 
union of the parts of the vertebral arches. 

Although the tumour is generally associated with a 
bifid spine, this is not necessarily the case. The pro- 
trusion may take place through the intervertebral 
notch or foramen, or there may be a fissure of the 
bodies of the vertebras, and an anterior tumour project- 
ing into the cavity of the thorax, abdomen, or pelvis, — 
spina bifida occulta. The principal anatomical varie- 
ties are meningocele, meningo-myelocele, and syringo- 
myelocele.* 

Meningocele. — In this form there is a protrusion 
of the membranes only (Fig. 129). The accumulation 
of fluid is either in the arachnoid cavity or the subarachnoid space poste- 
rior to the cord. The opening of communication between the tumour and 

the spinal canal is small in this variety, 
usually being about one twelfth to one 
sixth of an inch in diameter. There may, 
however, be no communication. The 
skin is usually fully developed (Fig. 130). 
The tumour is frequently globular, some- 
times pedunculated, and may attain a 
very large size, being as much as five or 
six inches in diameter. This is because 
spontaneous rupture is not likely to oc- 
cur, and the tumour does not become in- 
fected except by operative interference. 
With such tumours patients may live to 
adult life. This variety is most frequent- 
ly seen in the cervical region. It has 
the best chance of natural recovery, and 
in it operation gives the best results. 

Meningo-myelocele. — This is by far the 
most frequent variety of spina bifida, oc- 
curring in thirty-five of the fifty-seven 
cases reported by Demme. It is the form 

-tiG. 130. — Meningocele, in a child one r J 

year old. usually seen in the sacro-lumbar region. 

* See Report of London Clinical Society, 1885 : and Humphrey, Lancet, March 28, 
1885. 




SPINA BIFIDA. 



761 




The accumulation of fluid takes place in the anterior subarachnoid space, 
less frequently in the anterior arachnoid cavity (Fig. 131). In this form 
the cord is contained in the sac, and usually forms a part of its wall. 
The tumour is smaller than the meningocele, the usual size being that of 
a mandarin orange. It is sessile, never pedunculated. As a rule it is only 
partly covered by skin, but has a central area, elliptical in shape, where 
there is only a thin, translucent membrane. This sur- 
face, which is known as the central cicatrix, is some- 
times covered with granulations, and frequently ulcer- 
ates. The tumour often has a vertical furrow or a cen- 
tral umbilication, corresponding to the attachment of 
the cord on its inner surface. The usual relation of 
the parts is for the cord to run horizontally across 
the upper part of the tumour to the central cicatrix, 
with which it becomes blended, and from which again 
the nerves arise. These re-enter the canal at the lower 
part of the tumour, and are distributed below as usual. 
In other cases the cord joins the wall of the sac soon 
after its entrance, and its attenuated fibres are found 
spread out all over the sac, coming together again be- 
low and entering the spinal canal. 

The following case, upon which I recently made an 
autopsy, is a good example of the common variety: 
The child died on the third day after birth from rup- 
ture of the sac. The tumour occupied the sacral region. The first 
sacral vertebra was normal, and beneath this the cord passed, termina- 
ting in the cauda equina soon after entering the sac, and continued 
back to the central cicatrix. Here nerve filaments blended with the 
other tissues in an indefinite structure, from which again, with toler- 
able distinctness, they could be seen to pass over the wall of the sac and 
return to the canal. The afferent and efferent nerves and the part of the 
membranes they carried with them formed several septa, making a smaller 
separate sac within the larger one. The large sac was clearly a dilatation 
of the anterior subarachnoid space, and communicated freely with the 
same space in the cord above. 

Syringo-myelocele. — In this variety the accumulation of fluid is in the 
central canal of the cord, the lining of the sac being here the attenuated 
and atrophied cord elements. This is the rarest form of tumour, but the 
one most frequently associated with hydrocephalus, and consequently hav- 
ing the worst prognosis. It is usually found in the dorsal or dorso-lumbar 
region, rarely in the lumbo-sacral (Fig. L32). 

With spina bifida other deformities are frequently associated, the most 
common being club-foot, hydrocephalus, more rarely encephalocele or 
cerebral meningocele, and hare-lip. If hydrocephalus exists, there is in 



- Meningo- 
myelocele (partially 
diagrammatic). A, 
theniembranes ; B, 
the cord ; C\ the in- 
tegument. The ac- 
cumulation of fluid 
is in front of the 
cord, the filaments 
of which are spread 
out. forming a part 
of the wall of the 
sac. 



762 



DISEASES OF THE NERVOUS SYSTEM. 



r 





Fig. 132. — Syringo-myelocele of the mid- 
dorsal region, in a child four months 
old, who also had hydrocephalus. 



most cases a dilatation of the central canal of the cord and a direct com- 
munication between the tumour and the lateral ventricles of the brain. 

Pressure upon the anterior fontanel 
causes an increase in the size of the 
tumour, and conversely. Club-foot is 
usually double, most frequently tal- 
ipes equino-varus. In a number of 
cases there is a history of some de- 
formity in other members of the fam- 
ily. I once saw two successive chil- 
dren in the same family with spina 
bifida. 

Symptoms. — The tumour is pres- 
ent at birth, and is most frequently 
situated just above the sacrum. Pa- 
ralysis is frequent in myelocele and 
syringo-myelocele, but is not seen in 
meningocele ; its degree and its loca- 
tion depend upon the situation of the 
tumour and the extent to which the 
cord is involved. It is rare in cervi- 
cal tumours, and most marked in those situated in the lumbo-sacral re- 
gion. In the worst cases there is complete paraplegia, with paralysis of 
the bladder and rectum. If the tu- 
mour is sacro-lumbar or sacral, only 
the cauda equina is likely to be in- 
volved, and this but partially, so 
that the paralysis of the extremities 
is incomplete, and the bladder and 
rectum may escape. 

In Fig. 133 is shown a very re- 
markable case of sacral spina bifida 
in a boy of five years, who came 
under observation for incontinence 
of faeces. The tumour was a little 
more to the left than to the right 
side, and had been overlooked. It 
had evidently pressed upon the lower 
branches of the sacral plexus, so as 
to involve the sphincter and the 
gluteal muscles of the left side. The 
atrophy was very marked, as shown 
in the illustration. 

The natural course of spina bifida Fig. 133.— Sacral spina bifida. 




SPINA BIFIDA. 



'63 



is to increase steadily in size; and if the tumour is covered by skin, 
its growth may be almost unlimited. It has been known to attain a cir- 
cumference of twenty-two inches. If the integument is wanting, and the 
sac wall is very thin, rupture is pretty certain to take place, either 
spontaneously or by some accident, in the course of the first few months ; 
death then results from convulsions owing to the rapid draining away of 



7~-H8§fe_.. 

A 




the cerebro-spinal fluid, or from secondary infection. In a large number 
of cases death is due to marasmus dependent upon the associated condi- 
tions. Infection of the tumour may take place without rapture, the germs 
passing through the wall of the sac. If the opening communicating with 
the spinal canal is small, this infection may excite an inflammation limited 
to the wall of the sac, and result in a cure of the spina bifida, usually with 



764 DISEASES OP THE NERVOUS SYSTEM. 

sloughing. I have now under observation a girl ten years old in whom 
this occurred in infancy. The site of the former tumour is marked by a 
large dense cicatrix, and there still remains partial paralysis of the legs. 
If the opening into the spinal canal is large, inflammation of the sac is 
usually followed by spinal meningitis, which may extend upward and in- 
volve also the meninges of the brain. In a case published by Van Gieson 
and myself,* in which there was dilatation of the central canal of the 
cord and hydrocephalus, bacteria penetrated the wall of the sac and trav- 
elled up the central canal of the cord (Fig. 134), finally exciting a sup- 
purative inflammation in the ventricles of the brain, in addition to a 
spinal meningitis. Sections of the wall of the sac and of the cord at 
various levels showed the same cocci. The child died at the age of three 
weeks. 

Prognosis. — This depends chiefly upon the anatomical variety and the 
existence of complications. Simple meningocele, when covered by integu- 
ment, gives the best prognosis, and complete recovery may occur. In 
meningo-myelocele, if complete paralysis exists, the prognosis is bad ; and 
if there is hydrocephalus, the case is hopeless. In quite a number of 
cases in which cure has followed operation, hydrocephalus has subse- 
quently developed. Of fifty-seven cases reported by Demme, twenty-five 
were operated upon, with seven recoveries and fifteen deaths, while in three 
there was no result ; of the thirty-two cases not operated upon, twenty- 
eight died within the first month, and not one lived over two years, — the 
causes of death being marasmus, rupture of the sac, and meningitis. 

Diagnosis. — It is usually easy to recognise spina bifida, but it is often 
difficult to distinguish between the different varieties. The absence of 
a palpable fissure in the spine, perfect translucency, and a pedunculated 
tumour, all point strongly to meningocele. Paralysis of the sphincters 
and lower extremities, umbilication of the centre of the tumour, a sessile 
tumour, a palpable bony fissure, and a large central cicatrix, point to 
meningo-myelocele. The coexistence of hydrocephalus points to syringo- 
myelocele. 

Treatment. — In all cases the tumour should be protected from pres- 
sure, and care taken where it is not covered by integument, that the 
surface is kept absolutely clean and aseptic. It should be covered with 
iodoform and bismuth and surrounded by a large pad of absorbent cot- 
ton, or a rubber ring-cushion. Complete paraplegia with involvement 
of the bladder and rectum, hydrocephalus, or extreme marasmus, — all 
contra-indicate operative interference. In other cases, operation should 
be considered. The time of operation will depend somewhat upon the 
nature of the tumour. If it is covered by integument and growing slowly, 
it is well to wait until the child is at least six months old. In other cases 

* Journal of Nervous and Mental Diseases, December, 1890. 



SPINAL MENINGITIS. 765 

delay is dangerous, because of the liability to spontaneous or accidental 
rupture. 

Nothing is to be expected from simple aspiration and compression. 
The methods of treatment which have been successfully employed are as- 
piration and injection, ligation, and excision of the sac. The plan of aspira- 
tion and injection is the one to be advised in the majority of cases. The 
needle should never be inserted near the median line. The tumour hav- 
ing been aspirated and about one half its contents evacuated, there is in- 
jected, without removing the needle, a drachm of Morton's fluid (iodine, 
gr. x; iodide of potassium, gr. xxx ; glycerin, § j). If the tumour is 
pedunculated, pressure should be made at its neck to prevent the entrance 
of fluid into the canal. In all cases the child should be kept in a recum- 
bent position for several hours. The operation is not entirely free from 
danger, as in some cases it has been followed by convulsions and death in 
a few hours. Considerable inflammatory reaction usually occurs, lasting 
from two to four days. After this period there is, in a favourable case, a 
subsidence of the swelling, with a gradual contraction and finally oblitera- 
tion of the tumour. In some cases two or three injections may be required. 
The mortality of cases treated by this method is from forty to fifty per 
cent.* It is quite possible that with a proper selection of cases a larger 
proportion of recoveries may occur. My own experience includes four 
cases, with two recoveries. Although recovery may follow operation, in a 
very large number of cases it is incomplete ; some degree of paralysis, with 
atrophy, contractures, and deformities, remaining because of the implica- 
tion of cord elements in the sac. 

Ligation is admissible only where there is a pedunculated tumour; 
and even for these cases some surgeons prefer the clamp. The latter is an 
uncertain method, however. For a description of the various plastic opera- 
tions that have been proposed in connection with complete or partial 
excision of the sac, the reader is referred to works upon operative surgery. 
In estimating the value of such operations one point should not be forgot- 
ten, — that in the great proportion of the cases (ninety-five percent, accord- 
ing to the Clinical Society's Report, which, however, refers only to fatal 
cases) some part of the cord is in the sac. Although at birth the lower 
extremity of the cord is opposite the third lumbar vertebra, the cord is 
often present in tumours situated below this point on account of its attach- 
ment to the sac. 

SPINAL MENINGITIS. 

In acute meningitis usually only the pia mater is involved. This rarely 
occurs alone, unless it is due to traumatism. It is most frequently asso- 
ciated with inflammation of the pia of the brain, and may occur either with 

* Report of the London Clinical Society. 



>I66 DISEASES OF THE NERVOUS SYSTEM. 

the simple or the tuberculous variety. A certain amount of acute in- 
flammation of the pia mater accompanies most of the cases of acute my- 
elitis. 

Chronic spinal meningitis in children usually involves the dura only. 
Inflammation of the external layer (external pachymeningitis) is usually 
secondary to caries of the vertebrae. This is considered in the article 
on Compression-Myelitis. 

Symptoms. — The symptoms of inflammation of the spinal membranes, 
no matter with what pathological condition it may be associated, are due 
to irritation of, or pressure upon, the cord or nerve roots. Those which 
are most common are : pain in the back, which is increased by move- 
ment, and usually by pressure upon the spinous processes ; radiating pains 
following the course of the spinal nerves, felt in the extremities or in 
the trunk ; rigidity of the spinal column due to spasm of the spinal mus- 
cles, or rigidity of the muscles of the extremities ; and hyperesthesia 
along the spine, which may be quite acute. When pressure upon the cord 
is added, there is paralysis or paresis, sometimes muscular atrophy and 
anaesthesia. Any of the above symptoms may be acute or chronic, accord- 
ing to the nature of the primary disease. 

The diagnosis between spinal meningitis and myelitis is often not easy, 
for except in acute cases the two processes are usually associated ; and in a 
given case it may be difficult to decide whether the lesion of the cord or 
of the membranes is the more important one. In meningitis, pain, ten- 
derness, spasm, and irritative symptoms are generally more prominent, 
while loss of power and anaesthesia are usually partial. In myelitis the 
pain, tenderness, and other irritative symptoms are less marked, while 
paralysis and anaesthesia may be complete. 

Treatment. — This is first of the disease with which it is associated ; in 
addition, counter-irritation by means of the Paquelin cautery, rest in bed,, 
and in severe cases even immobilization of the spine by a mechanical sup- 
port. Iodide of potassium is often useful. 

MYELITIS. 

Myelitis is a rare disease in children, with the exception of two varieties^ 
which are discussed under separate heads, viz., compression-myelitis and 
acute poliomyelitis. Otherwise myelitis usually results from injury, but 
it may occur as a complication of any of the acute infectious diseases, -es- 
pecially typhoid or scarlet fever, and diphtheria, and even as a primary 
disease, where it is attributed to exposure or cold, but where it is probably 
infectious. Chronic myelitis may be due to hereditary syphilis. 

Myelitis usually occurs in children over ten years of age. In situation,, 
it may be transverse, diffuse, or disseminated ; the process may be acute, 
subacute, or chronic. The lesions and the symptoms are essentially the 
same as when the disease occurs in the adult. 



MYELITIS. 767 

Symptoms. — Myelitis usually comes on rather gradually, with only 
local symptoms; but the onset may be quite acute, with severe general 
symptoms, — fever, pain, prostration and localized or general convulsions. 
The local symptoms vary with the seat and the extent of the disease. 

In transverse myelitis loss of power and anaesthesia are present below 
the level of the lesion ; either of these may be partial or complete. At the 
level of the lesion there is a zone of hyperesthesia and " girdle-pains." 
All the reflexes below the seat of the lesion are exaggerated. Those at 
the level of the lesion are lost. There may be loss of control of the 
sphincters, bed-sores, degenerative changes in the paralyzed muscles, con- 
tractures, and vaso-motor disturbances. The paralyzed muscles may be 
rigid or flaccid according to the seat and extent of the lesion. 

When transverse myelitis is situated in the cervical region there are 
paralysis and anaesthesia of the arms, legs, and trunk. All the reflexes are 
exaggerated, and there is general rigidity of the paralyzed muscles. There 
are incontinence of faeces and retention of urine, followed by incontinence 
from overflow. The pupils are frequently contracted, and there may be 
optic neuritis. Atrophy, when present, usually affects the muscles of the 
arms, and indicates that the cord to a considerable extent is involved. 
There is great danger to life, owing to paralysis of the muscles of respiration. 

When the seat of disease is the dorsal region, the symptoms are similar 
to those above described, with the exception that the arms escape, and 
that the eye-symptoms are usually wanting. This is the most favourable 
seat for the disease. 

When the disease is situated in the lumbar region, in addition to para- 
plegia and anaesthesia of the legs, there is, from the beginning, inconti- 
nence of urine and faeces. The knee reflexes are lost ; the muscles atrophy, 
and usually give the reaction of degeneration. Bed-sores are frequent. 

In diffuse myelitis the symptoms are a combination of the above 
groups. If a large part of the cord is involved, there are general paraly- 
sis and anaesthesia, loss of reflexes, marked trophic disturbances, bed- 
sores, etc. 

The course of myelitis is slow, and it usually progresses steadily from 
bad to worse. Death is due to exhaustion or complications — cystitis, bed- 
sores, or hypostatic pneumonia— or to some intercurrent disease. In a 
small proportion of the cases there may be partial recovery, but very 
rarely is this complete. The diagnosis is to be made from spinal menin- 
gitis, tumours, and haemorrhage. 

Treatment.— The treatment of the early stage consists in the use of ice 
to the spine, or counter-irritation by means of dry cups, mustard, or the 
Paquelin cautery. Later, the iodide of potassium should be given in all 
cases; improvement may follow its use, even when there is no suspicion 
of syphilis, but large doses are required, and for a long period. Electricity 
is contra-indicated except in chronic cases, and then but little improvement 



768 DISEASES OP THE NERVOUS SYSTEM. 

is likely to result from its use. In these patients the most important thing 
is careful attention to cleanliness and to posture, in order to prevent bed- 
sores, cystitis* and pneumonia. 

COMPRESSION-MYELITIS. 

Synonyms : Pressure-Paralysis of the Spinal Cord ; Pott's Paraplegia. 

Compression-myelitis is usually the result of caries of the spine. It 
most frequently complicates this disease when the cervical or upper dorsal 
vertebrae are involved, it being quite rare when the lower half of the 
spinal column is affected. This difference is probably due to the smaller 
size of the spinal canal in its upper portion. According to Gibney,* para- 
plegia is seen in fifty per cent of the cases of caries of the upper half of 
the spine. Essentially the same condition, so far as the cord is concerned, 
may result from tumours of the spinal cord, or from anything else causing 
pachymeningitis. These, however, are exceedingly rare in childhood. 

Lesions. — In spinal caries there occurs as a result of tuberculous dis- 
ease a softening of the bodies of the vertebras, which fall together from the 
pressure due to the superincumbent weight of the body. This causes a 
backward projection known as the kyphosis, or angular deformity. The 
spinal canal is encroached upon by the remains of the vertebral bodies 
whose ligamentous attachments have been loosened, and also by inflam- 
matory products the result of periostitis, and localized inflammation of the 
dura mater, chiefly of the external layer, but which sometimes affects the 
internal layer also. All these conditions lead to the production of a mass 
of inflammatory material, often containing tuberculous deposits, which is 
chiefly in front of the cord, but may surround it. The compression takes 
place slowly in most of the cases, from the gradual progress of the lesions 
mentioned. In a small number of cases there may be a sudden pressure 
from the slipping backward of one of the vertebral bodies. 

In recent cases the cord at the seat of compression is a little smaller 
than normal. It is usually involved to the extent of from half an inch 
to two inches. Paraplegia may have existed where the changes found in 
the cord are very slight, and sometimes where no changes are visible to 
the naked eye. In more protracted and more severe cases, the cord is 
much smaller at the point of disease, and under the microscope shows the 
changes of interstitial myelitis (Growers) with meningitis. In old cases 
there are degeneration of the nerve elements, atrophy, and sometimes dis- 
appearance of the ganglion cells, with more or less destruction of the nerve 
fibres ; sometimes all distinction between the gray and white substance is 
lost. In addition to these marked changes at the point of pressure, there 
may be ascending or descending degeneration, as from other focal lesions. 

* Journal of Mental and Nervous Diseases, April, 1878. 



COMPRESSION-MYELITIS. 769 

There is usually inflammation of the nerve roots, which have also suffered 
compression. It is in many cases surprising to see to what degree the 
cord may be compressed and still preserve its functions. 

Symptoms. — In caries of the cervical region the symptoms of com- 
pression-myelitis not infrequently precede the deformity, and, in fact, the 
other objective symptoms of bone disease. The earliest symptoms of 
caries usually arise from irritation of the nerve roots, and consist of 
acute pains not often referred to the spine, but radiating to the differ- 
ent regions to which these nerves are distributed. They are felt in the 
neck, in the chest, in the epigastrium, and sometimes in the loins. Such 
symptoms indicate the presence of pachymeningitis, and may be present 
whatever the location of the vertebral caries. Accompanying these pains, 
there is noticed a gradual weakness in the lower extremities, and some- 
times also in the arms, according to the location of the disease. This 
may steadily increase for several weeks until there is complete paralysis. 
Other symptoms are then commonly present. There is usually some degree 
of anaesthesia, but in many cases there is none, and there may be numbness, 
tingling, formication, and pain. The sphincters are not often involved. 
When the disease is in the upper half of the cord, there are rigidity of the 
extremities and great exaggeration of all the reflexes, with marked ankle- 
clonus. In the rare cases in which the lumbar enlargement is involved, 
there may be loss of reflexes, paralysis of the sphincters and bed-sores. 

The distribution of the paralysis will depend upon the point of com- 
pression. If this is in the cervical region, all four extremities will be para- 
lyzed ; if in the dorsal region, only the legs. In rare cases the paralysis 
is unilateral, and if there is no spinal deformity the condition may be a 
most puzzling one. According to the extent of the secondary lesions in 
the cord, there may occur muscular atrophy and contractures. With dis- 
ease in the upper cervical region, death may result from sudden pressure 
upon the cord, owing to a dislocation of the odontoid process, which hap- 
pened in one of Gibney's cases ; or there may be vomiting, pupillary 
symptoms, irritation of the phrenic nerve causing hiccough, or pressure 
causing paralysis of the diaphragm. 

Course and Prognosis. — These depend much upon the treatment of the 
case. In many cases of paralysis occurring early in caries, complete re- 
covery takes place in the course of a few weeks, sometimes in a few days, 
after the application of a proper mechanical support. This may be true 
even where the paralysis has continued for three or four months. In the 
cases which have been long neglected, or those in which the paralysis de- 
velops while proper mechanical treatment is being carried out, the chances 
of improvement, or at least of rapid improvement, are not nearly so good. 
Gibney gives the following statistics of fifty-eigtH cases under his personal 
observation: thirteen proved fatal, six dying from myelitis five from 
other diseases subsequent to recovery from the paralysis, and two from 
58 



770 DISEASES OF THE NERVOUS SYSTEM. 

tuberculosis before complete recovery ; twenty-nine recovered from the 
paraplegia, but relapses occurred in eight, all but one of these, however, 
recovering subsequently ; fifteen cases were under observation at the 
time of the report. The usual duration of the disease is from twelve to 
eighteen months. Complete recovery has often taken place in cases that 
have persisted for four or five years. No case should be considered hopeless 
no matter how long the symptoms have lasted, unless there is marked 
atrophy "with loss of electrical reactions, and contractures have taken place. 

Diagnosis. — This is rarely difficult. Spinal caries should be suspected 
in every case where the symptoms point to transverse myelitis coming 
on without definite cause. The gradual onset, the radiating pains, the 
stiffness of the spine in walking, the gradual loss of power, the increased 
reflexes and ankle-clonus, — all are usually present and characteristic. 
They are sufficient to warrant the diagnosis of spinal caries, even when 
no deformity exists. When there is deformity, the symptoms are un- 
mistakable. 

Treatment. — The most important indications are the removal of pressure 
and the fixation of the spine by means of a proper mechanical support. If 
for any reason this is impossible, the patient should be kept in bed. The 
two other measures which promise most are the use of the Paquelin cau- 
tery, and the internal administration of potassium iodide. From his very 
extensive experience, Gibney has more confidence in this drug than in all 
else except mechanical treatment. Large doses are required, often from 
sixty to ninety grains being given daily for months. From personal ob- 
servation of many of Gribney's cases I can bear testimony both to the bene- 
ficial effect of the iodide, and to the ease with which it is generally borne 
by children in the doses indicated. Very often patients gained steadily 
in weight while taking the drug, and acne was the exception. The 
iodide should always be largely diluted. In all cases patients should be 
carefully watched, kept scrupulously clean, and the position changed fre- 
quently to prevent the formation of bed-sores. Electricity is contra- 
indicated. When the paralysis develops rapidly or occurs suddenly, relief 
may sometimes be obtained by the operation of laminectomy ; but little 
is to be expected from this in the slow cases. 

INFANTILE SPINAL PARALYSIS. 

Synonyms: Acute Poliomyelitis ; Acute Atrophic Paralysis. 

This disease is characterized by an acute onset, generally with febrile 
symptoms, by an early and usually extensive loss of power, and by a con- 
siderable degree of spontaneous improvement except in certain groups of 
muscles which remain permanently paralyzed, and undergo a very rapid 
and marked atrophy. A chronic form of the disease is described in 
adults, but this is rarely, if ever, seen in children. 



INFANTILE SPINAL PARALYSIS. 771 

Acute poliomyelitis is the most frequent cause of paralysis in early life 
and it is often designated simply as infantile paralysis. 

Etiology. — In 566* cases the age at which the paralysis developed was 
as follows : 

During the first year 20 per cent. 

" " second year 38 " 

" third year 22 

" " fourth, and fifth years .• 15 " 

After " fifth year 5 " 

From this table it will be seen that the great proportion of cases develop 
before the fifth year, and that eighty per cent of them begin during the 
first three" years, the most frequent period being the second year. 

Boys are rather more frequently affected than girls. In the series re- 
ferred to, fifty-five per cent were males and forty-five per cent were 
females. Hereditary influences seem to have but little effect in the pro- 
duction of this disease. It is rare to find several cases in the same family, 
or to trace any relation to nervous antecedents. The onset of the great 
proportion of the cases is in summer. Of Sinkler's cases, eighty per cent 
began during the five warm months. This fact is decidedly against the 
theory so often advanced, that the disease results from exposure to cold. 
There are, however, a few cases in which the connection between exposure 
and the disease seems to be a close one. On account of the time of on- 
set — most frequently in the second year — the disease is often ascribed 
to dentition. In my series this was given as the cause in one fifth of 
the cases. The connection is at most merely a coincidence. Traumatism 
is sometimes given as a cause, but the proportion of cases in which the 
paralysis can be fairly attributed to injury is very small, yet there are a 
few in which a definite injury of considerable severity has immediately pre- 
ceded the onset. In about twelve per cent of the cases above mentioned 
the paralysis came on as a sequel to some other acute disease ; this list in- 
cludes nearly all the diseases of infancy, those most frequently noted being 
diarrhoea, scarlet fever, and measles ; but in the great proportion of the 
cases the patient was in good health at the time of the attack. 

The essential cause of the disease is as yet unknown. On account of 
the close relation of the lesion to the distribution of the blood-vessels, 
there has been of late a disposition on the part of many observers to 
regard it as infectious, the cord changes being the result of infectious em- 
bolism or thrombosis. 

Lesions.— Infantile spinal paralysis is due to an acute inflammation 
of the gray matter of the anterior portion of the spinal cord. The late 

* These statistics and those which follow in this article are derived from the follow- 
ing sources: Sinkler, in Keating's Cyclopa'.lia, vol. iv, :*55 cases; Galbraith, American 
Journal of Obstetrics, 1894, 75 cases; the remaining 140 are personal cases and others 
taken from the records of the Hospital for Ruptured and Crippled, New York. 



Y72 DISEASES OF THE NERVOUS SYSTEM. 

changes which occur in the cord as a result of this process have for 
many years been well established ; but the early changes are even yet a 
matter of dispute, owing to the lack of opportunities of examining the 
cord during the stage of acute inflammation. 

In autopsies made upon cases of long standing, the part of the cord 
affected is distinctly smaller than normal. One lateral half is usually 
involved. The microscope shows that the ganglion cells are few in 
number or that they have entirely disappeared. Those that remain are 
shrunken and deformed and scarcely recognisable as ganglion cells. The 
entire gray horn is much smaller than that of the opposite side, and many 
of its normal elements have disappeared. The white matter also is 
smaller than upon the sound half of the cord. The anterior nerve-roots 
of the affected side are smaller than normal, and are degenerated quite 
to the muscles. The general changes in the cord are of a sclerotic char- 
acter. The affected muscles are degenerated, and there may be in ex- 
treme cases a complete disappearance of muscle fibres, their place being 
taken by adipose and fibrous tissue. In places where the lesion is less 
severe the fibres are small. The affected limb is shorter and the bones 
smaller than upon the sound side. These lesions are all secondary to 
those of the anterior ganglion-cells. 

The most recent observations upon the early stage of the process by 
Siemerling, Goldscheider, and others, tend to show that primarily the 
lesion is an interstitial inflammation, and not a parenchymatous one, as 
was formerly believed. Groldscheider's * theory of the disease is that the 
first changes are in the blood-vessels, from which the process extends to 
the neuroglia and produces a proliferation of cells ; the changes in the 
ganglion cells are degenerative in character, and are secondary to those 
just described ; the same is true of the changes in the nerve fibres. 
Accompanying the process in some cases small hemorrhages have been 
observed. 

The region of the cord most frequently involved is the lumbar en- 
largement, but there may be more than one focus of disease. Usually 
only one lateral half of the cord is affected, but it is not rare for both 
sides to be involved. In such cases the lesions are generally more ad- 
vanced upon one side than the other. 

Symptoms. — A frequent form of onset is for a child to be taken quite 
suddenly ill with vomiting, pains in the legs, or general hyperesthesia, and 
a temperature of from 101° to 103° P. After these symptoms have lasted 
a variable time, usually from one to four days, the paralysis is discov- 
ered. In a smaller number of cases — about ten per cent of the entire 
number — the attack is ushered in by more severe constitutional symp- 

* Goldscheider, Zeitschrift filr klin. Med., 1893, p. 494. See also Sachs, Nervous 
Diseases of Children, 1895, p. 310. 



INFANTILE SPINAL PARALYSIS. 773 

toms. There are convulsions, delirium, a temperature of 103° or 104° F., 
marked general prostration, constipation, severe pains in the back and 
extremities, — in short, all the symptoms of a severe acute inflammation. 
These symptoms last from two days to a week, often engrossing the 
attention of the physician, so that the paralysis may not be noticed until 
the patient has been sick for some time, or possibly not until the be- 
ginning of convalescence. In quite a large number of cases the general 
symptoms are very slight, and they may be absent altogether. A not 
infrequent history is that the child went to bed apparently well ; during 
the night was noticed only to be a little restless, and that the next morn- 
ing the paralysis was discovered. In two cases of my series the paralysis 
came on quite suddenly while the child was walking in the street, and 
was able to reach home only with considerable difficulty. In such cases 
it is not improbable that previous symptoms were present, but were so 
slight as to have escaped notice. 

In most of the cases there are pains in the back, in the muscles of the 
extremities, or along the course of the spinal nerves. With these pains 
general hyperesthesia is commonly associated, and there may be other 
disturbances of sensation such as numbness and tingling. The develop- 
ment of the paralysis is quite rapid, it often attaining its maximum in 
twenty-four hours ; although sometimes it will be two or three days, or 
even a week, before its full extent is seen. 

Extent and distribution of the primary paralysis. — In 560 cases in 
which this point was noted the distribution was as follows : 

One lower extremity 229 cases. 

Both lower extremities 176 

General paralysis of all extremities, and more or less of trunk 79 " 

One lower and one upper extremity 36 

Both lower extremities and one upper extremity 16 " 

One upper extremity alone 14 

Both upper extremities 2 

All other varieties 8 

In paralysis of the trunk, the diaphragm and other respiratory muscles 
are very rarely affected. In combinations of an upper and a lower ex- 
tremity, the limbs are more frequently affected upon opposite sides than 
upon the same side. The sphincters almost invariably escape. 

Course of the disease.— The rapid development of the paralysis is fol- 
lowed by a period of from one to four weeks' duration in which bu1 little 
change is seen in the affected muscles. This is followed by spontaneous 
improvement, which, according to Gowers, begins in fche muscles last 
affected, and generally reaches its limit in about three months. After 
this time but little spontaneous improvement is to be looked for, and the 
residual paralysis is likely to be permanent. By the end of two months 
marked atrophy is present in the paralyzed muscles. The affected limb 
is distinctly smaller than its fellow, this being quite apparent even in 



774 



DISEASES OF THE NERVOUS SYSTEM. 



infants. Except at the onset, sensory disturbances are absent ; the knee- 
jerk is lost in paraplegic cases, and in those in which the extensors of 
the thigh are paralyzed. There is arrested growth in the whole limb 
(Fig. 135). It becomes much smaller and shorter than its fellow. The 
great relaxation of the ligaments at the joints may allow subluxation, 
especially at the knee and at the shoulder. The circulation in the af- 
fected limb is poor ; it is often blue and cold, but bed-sores are never 
seen. 

Electrical reactions. — Very early in the disease the atrophied muscles 

begin to lose their power 
to respond to faradism. 
In the muscular groups 
which are to be perma- 
nently paralyzed, the fara- 
dic response may be lost 
in a week. The muscles 
in which recovery is to 
take place often preserve 
a certain degree of con- 
tractility, although this is 
less than normal, and im- 
proves later. The response 
to the galvanic current 
may be increased for a few 
months, and then slowly 
fail as the muscular fibres 
themselves degenerate, and 
at the end of two or three 
years it may disappear al- 
together. The reaction 
of degeneration is present 
with great uniformity in 
the atrophied muscles, but 
in them alone. 
Residual paralysis and deformity. — Only one lower extremity is in- 
volved in half the cases, and the paralysis is usually incomplete and con- 
fined to certain groups of muscles. The extensors both of the thigh and 
of the leg are nearly always involved to a greater degree than the flexors, 
and in very many cases only the extensor groups are paralyzed. The 
muscles most frequently affected are the anterior tibial group, and next 
the peroneal group. The most frequent deformity resulting from this 
paralysis is talipes valgus, and next to this talipes varus, both of these 
being usually associated with a certain amount of equinus. In very rare 
cases there is talipes calcaneus. Most children with paralysis of only one 




Fig. 135. — An old case of infantile spinal paralysis of the 
entire left lower extremity, showing extreme atrophy 
of the thigh and leg, and a very characteristic deform- 
ity of the foot. 



INFANTILE SPINAL PARALYSIS. 



775 



lower extremity are able to walk alone, or with the assistance of a steel 
brace. 

Paralysis of both lower extremities is the next in frequency. This 
also is rarely complete. In forty-three cases of my series there was 
originally complete paraplegia, but it was permanent in only three. The 
extent of recovery varies much in different cases. Usually one leg re- 





Fio. 186.— An old case of infantile spinal paralysis of the lefl arm and Bhoulder musoles, with 
resulting lateral curvature. The spinal deformity is increased by the fact that the patient 

had also suffered from empyema of the left side. 



covers to a much greater' degree than the other. Most of these patients 
are able to walk with the assistance of braces, a few only by the aid of 
crutches. Some walk while they are young, bnt are unable to do so 
when fully grown, because the disproportion between the size of the body 
and the limbs is then much greater. 



776 DISEASES OF THE NERVOUS SYSTEM. 

Paralysis of one upper extremity rarely occurs alone, but is associated 
with paralysis of one or both lower extremities. Complete paralysis of 
an arm is rarely, if ever, seen. The muscular groups affected may be the 
small muscles of the hand, the muscles of the forearm, — especially the 
extensors, — or the shoulder group. Of single muscles, the one most 
frequently involved is the deltoid ; this may result in subluxation of the 
shoulder. From paralysis of the muscles of the trunk or shoulder of one 
side, lateral curvature may develop (Fig. 136). If the serratus magnus is 
affected the scapula stands out prominently, giving rise to the so-called 
" angel-wing " deformity. 

Diagnosis. — The general symptoms of the onset have nothing charac- 
teristic about them, and no diagnosis can be made until the paralysis has 
taken place. The acute onset, the rapid wasting, the spontaneous im- 
provement in certain groups of muscles, the absence of sensory symptoms, 
and finally the reaction of degeneration, — all constitute a type which it is 
difficult to confound with any other disease. 

At the onset this paralysis may resemble that resulting from acute 
transverse myelitis. In the latter, however, we get anaesthesia, exagger- 
ated knee-jerk, ankle-clonus, generally involvement of the sphincters, 
a tendency to bed-sores, slight wasting, and no reaction of degeneration. 
It is, besides, extremely rare. 

Multiple neuritis is in most cases easily distinguished from poliomye- 
litis by its gradual onset, by the presence of pain and other sensory symp- 
toms as well as loss of power, and by the fact that spontaneous recovery 
generally occurs within two or three months. Besides, there is usually a 
history of antecedent diphtheria. But multiple neuritis sometimes begins 
suddenly with febrile symptoms, and paralysis may occur early, precisely 
as it does in poliomyelitis. Furthermore, in some cases of neuritis, the 
sensory symptoms are not marked, and they may have entirely disappeared 
before the patient is seen. In such cases the diagnosis from poliomyelitis 
may be difficult or even impossible except by the course of the disease ; 
for atrophy is common to both conditions, and even the electrical reac- 
tions may be identical. There is no doubt that some cases formerly re- 
ported as examples of poliomyelitis terminating in complete recovery were 
really cases of multiple neuritis. 

The diagnosis from acute cerebral palsy is chiefly difficult when the 
spinal paralysis has been hemiplegic or diplegic in type, or when after 
cerebral hemiplegia the leg or the arm has recovered so completely 
that the case resembles monoplegia. In cerebral palsies there is usually 
rigidity ; there is no reactiou of degeneration ; other cerebral symptoms 
are commonly present, or there is a history of an onset with cerebral 
symptoms; and the atrophy is less marked. The most diagnostic point 
is the electrical reactions. 

Infantile spinal paralysis may be mistaken for other than nervous dis* 



INFANTILE SPINAL PARALYSIS. 777 

eases. In the early stage it may be confounded with the pseudo-paralysis 
of scurvy. I have several times seen the mistake made of diagnosticating 
paralysis where scurvy was present. In scurvy, however, there are seen 
excessive tenderness and hyperesthesia, pain upon motion, especially about 
the knees, spongy gums, and sometimes ecchymoses about the joints. The 
muscular weakness of rickets is sometimes mistaken for infantile paralysis. 
However, in rickets the symptoms are always bilateral, the electrical reac- 
tions are normal, and other signs of rickets are present. In all doubtful 
cases the chief reliance for the diagnosis of paralysis should be placed 
upon the character of the electrical reactions. The lameness resulting 
from paralysis may resemble somewhat that due to hip-disease ; but with 
a careful examination there can rarely be any difficulty in making the 
differential diagnosis. 

Prognosis. — Infantile spinal paralysis is accompanied by little, if any, 
danger to life. It is possible that death may take place during the stage 
of acute inflammation, but this is certainly extremely rare. The most 
important question in early prognosis is whether there will be any per- 
manent paralysis, and, if so, what will be its extent. The important 
symptoms for prognosis are the amount of wasting and the condition of 
the electrical reactions. Muscles which in ten days have lost completely 
their faradic contractility are almost certain to waste rapidly and severely. 
The best indication of coming improvement is the return of faradic con- 
tractility. If this is completely lost for six months, recovery is doubtful ; 
^if for one year, improvement in these muscles, is not to be expected. If 
faradic contractility has never been lost, very great and early improvement 
in the paralyzed muscles may be confidently predicted. After three 
months but little spontaneous improvement is to be looked for, and after 
two years none at all. Complete recovery is possible only with a lesion 
of very limited extent ; and while it may occur, it is so infrequent that it 
is never to be expected. 

Treatment. — Unfortunately, most of the cases do not come under ob- 
servation during the acute stage, or the nature of the disease is overlooked 
until the paralysis has occurred. In the early stage the indications are, to 
induce free perspiration by hot baths, to keep the patient in a prone or 
lateral position, and to use counter-irritation to the spine by means of 
dry cups, mustard, or the Paquelin cautery, or an ice-bag may be placed 
along the spine. The natural course of the disease is to be kept in mind, 
for the tendency is to overestimate the effect upon the paralysis of the 
drugs used in the early stage. On theoretical grounds, ergoi is indicated, 
but it is doubtful whether any drugs have much effect. 

After all acute symptoms have subsided, or at the end of two or three 
weeks, electricity may be used, but its curative effects bave been very 
greatly overestimated. The object in using electricity is to keep up the 
nutrition of the muscles until the cord has recovered, which it is almost 



778 DISEASES OF THE NERVOUS SYSTEM. 

certain to do to a considerable degree. But no amount of electrization 
can preserve muscles whose ganglion cells have completely disappeared. 
These continue to waste and lose their faradic contractility, no matter 
how early electricity is begun nor how faithfully it is continued. Faradism 
may be used for such groups as respond to it ; otherwise galvanism should 
be employed. The beneficial results from electricity are to be obtained 
in the first year, chiefly in the first six months. Too much can not be 
said against the routine use of electricity in cases which have been para- 
lyzed three or four years, with the vain hope that some good may be done, 
even though there is no response to either current. Strychnine may be 
used in conjunction with electricity after all symptoms of central irrita- 
tion have subsided, but there is still great diversity of opinion regarding 
its effect. 

Friction and massage are of undoubted value in improving the circula- 
tion and the nutrition of a limb, and should be continued regularly twice 
a day for a long period. 

Mechanical Treatment. — The first use of mechanical appliances is the 
prevention of deformity. All cases of paralysis should be carefully 
watched, and braces applied as soon as any tendency to deformity from 
muscular contraction shows itself. This is much easier than to overcome 
deformities which have been allowed to develop, and quite as important 
for the patient. The second use of apparatus is to furnish support to the 
limb in order to enable the child to walk. By such means many get 
about with tolerable comfort, for whom locomotion without apparatus 
is impossible except with crutches. The third purpose of apparatus is, to 
overcome existing deformities in neglected cases.* Braces are generally 
used in conjunction with myotomy or tenotomy of the various shortened 
tendons, excision of portions of elongated tendons, and the production 
of artificial anchylosis in cases of " flail joints." By these means the 
orthopaedic surgeon is able to give a great deal of relief to these unfortu- 
nate and sometimes helpless patients. 

On the whole, the treatment is extremely unsatisfactory, and the result 
depends upon the severity and extent of the original disease, rather than 
upon the particular line of treatment adopted or the time at which it is 
begun. 

TUMOURS OF THE SPINAL CORD. 

Tumours of the cord are exceedingly rare in childhood, and almost 
unknown in infancy. The most common varieties seen in early life are 
glioma, sarcoma, and tuberculous tumours. Eisenschitz has reported a 
case of tuberculous tumour in the dorsal region occurring in a child of 

* See Gibney, New York Medical Journal, April 3, 1886, On the Limitation of 
Therapeutics in Infantile Paralysis. 



SYRINGOMYELIA. 779 

three and a half years. There was a similar growth in the cerebellum. 
The symptoms were essentially those of compression-myelitis. 

In my service at the Babies' Hospital I recently had a case of glioma 
of the cord in a child only one year old, which was in many respects 
unique. The early symptoms were gradual paralysis of the upper extrem- 
ities, to which were added later, stiffness of the neck, and finally immo- 
bility of the head, — the position being that of typical cervical caries. 
During the sixteen days of observation there was high fever, from 101° to 
104° F. There were no pupillary or vaso-motor symptoms. At the au- 
topsy the cord was found to be the seat of a diffuse gliosis. In the cer- 
vical region there was marked enlargement, the cord being fully four times 
its natural size. A microscopical examination by Dr. C. A. Herter showed 
that the growth apparently began in the vicinity of the central canal, 
and that the gliomatous process involved the entire length of the cord.* 

A somewhat similar case has been reported by Miura in a boy of 
eight years. 

The diagnosis of tumours of the spinal cord in infancy is practically 
impossible. In later childhood they are most apt to be mistaken for 
Pott's disease, but the symptoms are the same as those seen in tumours of 
adult life. 

SYRINGO-MYELIA. 

Syringo-myelia, although a rare disease, is sometimes seen in early life. 
The term is applied to a condition in which there is a cavity in the cord 
the result of a pathological process, in contradistinctiou to the cases in 
which a cavity is the result of a malformation, or hydromyelus, although 
it is not infrequent for the two conditions to be associated. The patho- 
logical process which precedes the cavity formation is now thought 
to be, in most cases at least, an infiltration of the substance of the 
cord with gliomatous cells. The process is somewhat similar to that 
described in the case of tumour of the spinal cord, with the exception 
that where it results in cavity formation it is slower. The infiltration in 
these cases usually begins near the central canal. It is followed by a de- 
generation and breaking down of the infiltrated areas, beginning at the 
centre. As the cavity forms it extends, and usually first invades the graj 
matter of the commissure, later the posterior gray horns, tin- posterior 
columns, or the anterior horns. The resulting cavity is usually irregu- 
lar in shape, and may be very small, or may extend through a large pari 
of the length of the cord. It is most frequently situated in the lower 
cervical and upper dorsal regions. It is filled with fluid, and surrounded 
by gliomatous tissuo. 

* For a full report of this case by Dr. Berterand myself, see American Journal of 
the Medical Sciences, April. L895, See also Kohts, Beitrag zur Diagnostik der Rttck- 

enmarkstumoren im Kindesalter, Dresden, lb8G. 



780 DISEASES OF THE NERVOUS SYSTEM. 

According to Starr, the essential symptoms are of three kinds : (1) 
There is progressive muscular atrophy, with paralysis of some or all the 
muscles of one limb, usually extending to the opposite limb and to the 
trunk, sometimes accompanied by the reaction of degeneration ; (2) vaso- 
motor and trophic disturbances in the affected limb, such as cyanosis, 
coldness, bullous eruptions, ulceration, abscesses, atrophy, and sometimes 
fragility of the bones and diminution of perspiration ; (3) sensory dis- 
turbances, which are probably the most characteristic symptoms of the 
disease, — there is loss of the sense of pain and of temperature in the atro- 
phied part, while the sense of touch and of location may be preserved. 
The extent and distribution of these symptoms will of course depend 
upon the position of the disease. 

The course of syringo-myelia is essentially chronic, the duration being 
usually several years ; and although spontaneous arrest sometimes occurs 
the disease is in most cases steadily progressive. 

The cause is unknown, and it is not influenced by any form of 
treatment. 

FRIEDREICH'S ATAXIA. 

This is a chronic disease of the spinal cord and medulla, which begins 
most frequently in childhood or about puberty. The lesion affects first 
the posterior columns, afterward the crossed pyramidal tracts, the direct 
cerebellar tracts in the lateral columns, and Clarke's vesicular columns 
in the gray matter of the cord. There is probably some disease of the 
medulla, the pons, and possibly of the cerebellum and the posterior 
nerve-roots. In advanced cases other parts of the cord may be involved. 
The disease is seen in certain families, often affecting several mem- 
bers in succession at about the same age. It occurs particularly in 
families where alcoholism, insanity, and other nervous diseases are fre- 
quent. 

Bramwell, in his monograph upon this disease, gives the following as 
the characteristic symptoms : There is ataxia, first of the lower extremities, 
but gradually extending to the upper extremities and the face. Early in the 
disease there is some weakness in the legs, especially in the anterior group 
of muscles. In the late stages this is marked and accompanied by atrophy. 
The gait is peculiar, like that of ordinary ataxic patients, the difficulty in 
walking being due to the ataxia and not to the paresis. After a time there 
is produced a characteristic deformity of the foot, — it is shortened, as if 
from pressure against the toes and the heel, the instep is high, and the ex- 
tensor tendon of the great toe stands out prominently. This deformity is 
seen quite early in the disease. There is often lateral curvature of the 
spine. The knee-jerk is absent. Unprovoked and uncontrollable laughter 
is quite a characteristic symptom of the disease. The patient is unable to 
stand with his eyes closed. There are palpitation, occipital headache, and 



THE MUSCULAR ATROPHIES. 781 

sometimes vertigo. In the later stages speech is slow and difficult, and 
the patient talks like one intoxicated. The expression of the face is 
vacant, and often nystagmus is present. There may be choreic move- 
ments. The symptoms steadily progress until the patient may be help- 
less, although the general health may remain good for years. 

The disease is distinguished from locomotor ataxia by the absence of 
the " lightning pains," and of the bladder, rectal, or genital symptoms, the 
pupillary changes, the optic-nerve atrophy, and the trophic changes in the 
bones and joints. It is distinguished from cerebral tumour by the absence 
of headache, vomiting, and optic neuritis, and by its longer course. The 
progress of the disease is slow but steady. It may last from twenty to 
thirty years. It is incurable. 

LANDRY'S PARALYSIS (ACUTE ASCENDING PARALYSIS). 

This rare disease is occasionally seen in early life. In regard to its eti- 
ology but little is definitely known, the usual causes assigned being the 
same as those of myelitis. 

It is characterized by a paralysis — sometimes preceded by general 
symptoms of malaise, fever, etc. — which begins in the legs and spreads 
rapidly to the muscles of the trunk and upper extremities ; finally it may 
involve the neck, diaphragm, and muscles of articulation. The paralysis 
develops quite rapidly, often attaining its height in from twenty-four to 
forty-eight hours, sometimes even proving fatal within this time. In 
other cases it comes on gradually, and may be two or three weeks in reach- 
ing its maximum. There is dyspnoea from involvement of the muscles of 
respiration. The paralyzed muscles are flaccid. There is hyperesthesia, 
followed by partial or complete anaesthesia and loss of reflexes. There are 
no changes in the electrical reactions, no atrophy, no bed-sores, and usually 
no involvement of the sphincters. Occasionally the arms may be affected 
before the legs, and even the bulbar symptoms may be the first noticed. 
Death is the most frequent termination, and in fatal cases the disease lasts 
from two days to a week. If recovery takes place, it is after two or three 
months of illness. 

The pathology of the disease is as yet unknown. The indications for 
treatment are the same as in acute myelitis, for in the beginning the two 
diseases can not usually be distinguished from each other. 

THE MUSCULAR ATROPHIES. 
These cases may be broadly divided into two groups, following in the 
main the classification of Sachs:* (1) Those dependent upon disease of 
the spinal cord,— the spinal atrophies; (2) those which are primarily dis- 
eases of the muscles themselves, — the idiopathic atrophies. 

* New York Medical Journal, December 15, 1888. 



782 DISEASES OF THE NERVOUS SYSTEM. 

In the group of atrophies of spinal origin belong (1) the "hand type " 
of Aran and Duchenne, which has been shown to be dependent upon a 
lesion of the spinal cord ; (2) the " peroneal type " of Charcot, Marie, and 
Tooth, which as yet lacks positive pathological proof of its spinal origin, 
although its etiology, symptoms, and course leave but little doubt that it 
belongs in the same category with the hand type. 

In the second group are included (1) pseudo-muscular hypertrophy, 
and (2) the so-called " juvenile atrophy " of Erb, which is a much less 
frequent condition. These two varieties have the following features in 
common : There is progressive wasting, beginning early in childhood, and 
associated at some period with hypertrophy of certain muscles. There are 
no fibrillary contractions, no reaction of degeneration, and no lesions in 
the cord. From a pathological point of view these diseases might be 
more properly considered elsewhere, but they are so closely associated clin- 
ically with the spinal atrophies that it has seemed better to describe them 
in this connection. 

Progressive Muscular Atrophy of the Hand Type.— This disease is char- 
acterized by a very slow but progressive wasting, which usually begins in the 
muscles of the ball of the thumb of one or both hands. Then the palmar 
group of muscles belonging to the little finger are affected, and later the 
interossei. When the wasting has reached a certain degree, there is 
produced a peculiar and characteristic deformity of the hand known as 
main en griff e, or " claw-hand." Following these muscles, those of the 
forearm may be affected. At this point the disease is sometimes arrested, 
or the atrophy may extend to the muscles of the arm and shoulder, espe- 
cially the deltoid, and finally to those of the back. Exceptionally, the 
atrophy begins in the muscles of the shoulder group or even in those of 
the leg. The wasting takes place very slowly, the muscles disappearing 
fibre by fibre, but the degree which may be reached is often extreme. 
The only other characteristic symptoms are fibrillary contractions in the 
muscles which are soon to atrophy. The patient is not conscious of them, 
but they are visible. The faradic contractility is preserved just in propor- 
tion to the amount of muscle remaining. If the atrophy is complete, it is 
entirely lost. 

The course of the disease is a very chronic one, covering many years. 
It is incurable. In rare cases the process may extend to the muscles of 
the tongue, affecting deglutition and articulation, and death may occur 
from interference with respiration ; otherwise the disease does not tend to 
shorten life. 

In this form of atrophy heredity is an important etiological factor. 
The disease may occur in children, but very often does not begin until 
after puberty. The lesion consists in an atrophy of the ganglion cells of 
the anterior horns of the spinal cord, followed by secondary degeneration 
of the anterior nerve-roots. 



THE MUSCULAR ATROPHIES. 783 

Progressive Muscular Atrophy of the Peroneal Type. — This is much less 
frequent than the variety just described. In this form, the first to waste 
are the anterior muscles of the leg, especially the extensor longus hallucis 
and extensor communis digitorum, afterward the peroneal group. The 
small muscles of the foot are next affected, and the disease may then go 
on to involve the muscles of the calf. At this point it may be arrested 
permanently, or for several years, after which the thigh muscles may waste 
like those of the leg. After many years the hands are in some cases involved 
as in the type previously described, and even the muscles of the forearm. 
As a rule, the supinator longus, the muscles of the shoulder, neck, trunk, 
and face, escape altogether. The atrophy is generally symmetrical, but 
not invariably so. The cutaneous reflexes are usually present. There is 
no pain. The reaction of degeneration is present in some of the muscles, 
and fibrillary contractions are frequent, but not always seen. 

In this variety also the influence of heredity may often be traced. It 
is said that boys usually inherit the disease through the mother. Like 
the previous type, it begins late in childhood or not until after puberty. 

As stated above, positive proof that this disease is due to a central 
lesion in the cord is as yet lacking. Analogy, however, leads to the belief 
that it depends upon changes in the ganglion cells of the anterior horns 
in the lumbar region, similar to those found in the cervical region in the 
hand type. The course of the disease is very chronic, and it, too, is incur- 
able. The resulting deformity resembles that seen after poliomyelitis, and 
may require the same mechanical treatment, with similar operations for 
relieving contractions. 

Pseudo-Muscular Hypertrophy (Pseudo-Hypertrophic Paralysis). — This 
is the most frequent and best-known variety of the idiopathic atrophies. 
It is a disease of certain families, often three or four children being af- 
fected, the boys much more frequently than the girls. The symptoms as 
a rule come on early in childhood, nearly always before the tenth year. 
The earlier symptoms relate to a general weakness of the lower extremities, 
which is accompanied by a marked increase in the size of certain muscular 
groups, usually those of the calves, but sometimes more of the thighs or 
the gluteal regions. Children walk late and unsteadily, and fall very easily. 
They have special difficulty in rising from the floor and in mounting 
stairs. The method of rising is quite characteristic: the patient lifts his 
body until he touches the floor only with the hands and feet; then he 
proceeds to "climb up himself" by putting first one hand upon the 
knee, and then the other, gradually moving his hands higher and higher 
up the thighs until the erect position is attained. This is seen in most 
of the cases, but not in all. 

The size attained by the calves is sometimes very great Gowers men- 
tions a case in which a boy of twelve had calves measuring fourteen and a 
half inches in circumference. The enlargement may affect almost any 



784 



DISEASES OF THE NERVOUS SYSTEM. 



muscular group of the lower extremity. In the upper extremity, the in- 
fra- spinatus is most frequently enlarged, next the supra-spinatus and the 
deltoid. The pectorals and latissimus dorsi are never enlarged, but are 
generally markedly wasted. Most of these patients exhibit while standing 
a marked degree of lumbar lordosis, due to the weakness of the extensors 
of the hip. This is well shown in Fig. 137. The patient may be so weak 

upon his legs that the slightest touch 
will cause him to fall, even with his 
apparently immense muscular devel- 
opment. The small muscles are gen- 
erally weaker than those which are 
enlarged. 

Later in the disease marked atro- 
phy occurs with a corresponding 
weakness of all the affected groups, 
and the patient may be unable to 
walk or even stand. With the ex- 
ception of the use of his hands, he 
may be absolutely helpless. The 
knee-jerk is at first normal, but grad- 
ually diminishes until it is finally 
lost. The electrical reactions are 
normal until marked wasting occurs, 
when there is a lessened response to 
faradism and galvanism, but never 
the reaction of degeneration. There 
are no fibrillary contractions, and no 
sensory disturbances. The progress 
of the disease is generally slow, and 
sometimes irregular. It is often more 
rapid in early childhood, and slower 
after puberty. 

The lesions are confined to the 
muscles. At autopsy they appear 
yellow, and microscopically there is 
found very marked atrophy of the 
muscle fibres, which in places have 
been almost entirely replaced by fat ; 
there may be no trace of muscle left, 
the structure resembling adipose tissue. In other places there is an accu- 
mulation of fat between the atrophied muscle fibres, and a very great 
increase of the interstitial tissue. 

The prognosis is grave, most patients dying before adult life is 
reached. The diagnosis is generally easy from the apparent hypertro- 




Fig. 137.— Pseudo-muscular hypertrophy, 
showing to a moderate degree the large 
calves and gluteal regions with a marked 
lordosis. (From a photograph by Dr. M. 
A. Starr.) 



MULTIPLE NEURITIS. 785 

phy and actual weakness of the muscular groups. The disease is incur- 
able. 

The Juvenile Form of Muscular Atrophy. — This is much less frequent 
than the form just described, but, like it, begins in childhood or early 
youth. It is characterized by progressive wasting of certain muscular 
groups, especially those about the shoulders and pelvis, and hypertrophy of 
others. Of the shoulder and upper extremity, the muscles affected are the 
pectorals, the trapezius, the latissimus dorsi, the serrati, the rhomboidei, 
the muscles of the upper arm, and the subscapulars. The deltoid, infra- 
spinatus and supra-spinatus for a long time escape, and may be hyper- 
trophied. The hand and forearm are not involved. In the lower extrem- 
ity, the muscles of the pelvis, thighs, and gluteal regions are affected, 
while those of the leg and foot escape. With this atrophy there may be 
associated a true or pseudo-hypertrophy of certain muscular groups. In 
this disease there are no fibrillary contractions, no reaction of degenera- 
tion, and no sensory disturbances. The course and result of this form 
are essentially the same as in the preceding variety. ' It is now generally 
regarded as closely allied to it in its pathology, the most important dif- 
ference being that of localization. 

There has been described, chiefly by Ladouzy and Dejerine, another 
form of atrophy known as the infantile facial type. In this, wasting be- 
gins in the muscles of the face ; the lips are thickened, but all the rest of 
the facial muscles are markedly atrophied, giving a peculiar expression to 
the mouth known as " the tapir mouth." Later, the atrophy extends to 
the shoulders and arm, but does not involve the supra-spinatus or infra- 
spinatus, or the flexors of the hand and forearm. This is sometimes de- 
scribed as beginning in the shoulders, or even in the legs. The descrip- 
tion therefore corresponds to the juvenile form of Erb, with the addition 
of facial symptoms, and it is probably a variety of the same disease. 



CHAPTER V. 

DISEASES OF THE PERIPHERAL NERVES. 

MULTIPLE NEURITIS. 
Under the term multiple neuritis are included those cases in which 
several nerves are involved in an inflammatory process, which may at times 
be general. In its distribution multiple neuritis is nsually symmetrical, 
but it is not necessarily so. 

Etiology. — The chief cause of multiple neuritis in children is diph- 
theria, although it is occasionally seen after other infectious diseases, 
especially malaria, typhoid or scarlet fever, and measles. In diphtheria 
59 



786 DISEASES OF THE NERVOUS SYSTEM. 

the inflammation is due to the direct action of the toxines upon the nerve 
structures, since it can be induced in animals by injecting toxines into 
the circulation. There is little doubt that in all infectious diseases the 
inflammation is excited in a similar way. The metallic poisons, lead and 
arsenic, are rarely the cause of multiple neuritis in early life, and the 
same is true of alcohol, although a marked case from this cause has 
recently come under my observation in a child only three years old.* 
Lastly, there are cases in which the cause assigned is simply exposure to 
cold, — those classed as rheumatic. 

Lesions. — Almost any nerves in the body may be affected, although 
the distribution varies somewhat with the cause of the disease. The 
musculo-spiral and the anterior tibial nerves are most frequently involved, 
but the inflammation may affect any of the spinal nerves, including the 
phrenic, and occasionally the cranial nerves, especially the pneumogas- 
tric hypoglossal, oculomotor, and abducens. Several nerves in different 
parts of the body are usually affected, the lesion being in most cases sym- 
metrical. 

The affected nerve is sometimes red and swollen, owing to acute conges- 
tion and oedema or a sero-fibrinous exudation. In other cases the changes 
are almost entirely degenerative. The microscope shows the changes 
sometimes to be chiefly interstitial and sometimes chiefly parenchymatous. 
There is an exudation of cells into the sheath, between the sheath and 
the nerve fibres, and even between the nerve fibres themselves. The 
myeline breaks up into granules, and in places may completely disappear. 

* This case was in many respects a remarkable one. The boy completely emptied a 
decanter containing twelve ounces of whisky, but almost immediately vomited the 
greater part of it. He soon after showed the symptoms of alcoholic intoxication, and 
in a few hours became comatose, in which condition he continued for twelve hours. 
After this he gradually lost power in his legs, and at the end of a week was unable to 
walk at all. He had convulsions, and after this there developed the usual symptoms 
of meningitis at the convexity, with which he was admitted to the Babies' Hospital, 
December 13, 1895, three weeks after drinking the whisky. The child was then un- 
conscious and there was present incomplete paralysis, affecting all four extremities, 
with anaesthesia of the arms. The active inflammatory symptoms continued for six 
weeks longer, during which time there were repeated convulsions, continuous stupor, 
fever, gradually increasing deformities, marked atrophy, loss of reflexes, and great dimi- 
nution in the faradic contractility of all the paralyzed muscles ; in the thighs, left leg, 
and abdominal muscles there were no responses to a strong current, but there was no- 
where the reaction of degeneration. The child was at death's door for three or four 
weeks. Three months after the attack the first signs of improvement were observed in 
the cerebral symptoms. Shortly afterward he began to use his hands, and at the end 
of six weeks he was walking alone and talking freely. The improvement was very 
rapid, and eight weeks from the date of the first change for the better, and five months 
from the time of taking the whisky, he was as well as ever. The diagnosis was mul- 
tiple alcoholic neuritis, with a convexity meningitis. (Fig. 138 is from a photograph 
taken while the symptoms were at their height.) 



MULTIPLE NEURITIS. 787 

The late changes are those of subacute or chronic degeneration of the 
nerve fibres.* 

With these changes in the nerves there are associated, in some cases, 
inflammatory and degenerative changes in the ganglion cells of the spinal 
cord, although they are much less severe than are the lesions in the nerves. 
However, they were once regarded as the explanation of some of these 
cases, particularly of diphtheritic paralysis. 

Symptoms. — The onset of multiple neuritis is in most cases a grad- 
ual one, it being usually from two to four weeks before the paralysis 
reaches its height. Very exceptionally the onset may be abrupt, witb 
fever, and marked paralysis in a few days. It is characteristic of this 
disease that both motor and sensory symptoms are present, and that they 




Fig. 138. — Alcoholic neuritis, showing characteristic dropping of the feet This position of the 
lower extremities was maintained for over a month. Boy three years old. 

are the same in their distribution. The symptoms are usually symmet- 
rical. There is first noticed a general weakness in the affected muscles, 
which slowly increases to complete paralysis. As the extensor groups 
of the hands and feet are apt to be affected, there are wrist-drop and 
foot-drop (Fig. 138). The paralysis may begin in the feet and hands, 
and gradually extend until it involves not only the four extremities, but 
even the muscles of the trunk and the neck, although this Is rare. The 
child may then be absolutely helpless, unable to sit up, or oven to support 
its head. In such cases the head seems loosely attached to the body, and 
rolls about on the shoulders like a ball. Weakness of the spinal muscles 
leads to deformities (Fig. 139), which I have seen mistaken for Pott's dis- 



* For a full description of the lesions, consult Starr's Middleton-Goldsmith Lectures, 

New York Medical Record, 1887. 



788 



DISEASES OF THE NERVOUS SYSTEM. 



ease, even by experienced observers. In most of the muscular groups 
the paralysis is incomplete. The symptoms which relate to the phrenic 
and the cranial nerves will be described with Diphtheritic Paralysis, for 
they are rarely seen in any other form. It is characteristic of multiple 
neuritis that the bladder and rectum escape. 

The sensory symptoms are marked only in the early stage of the dis- 
ease, while the paralysis is increasing ; they improve so much more rap- 
idly than the motor symptoms, that they 
may be altogether wanting at the time 
that the paralysis is at its height. In 
some cases they are so slight as to be 
overlooked. There is usually pain along 
the course of the affected nerves, which 
is sharp and neuralgic in character, and 
generally associated with acute tender- 
ness of the nerve trunks and of the mus- 
cles. Often there is a general hyperes- 
thesia in the early part of the attack, 
followed by partial anaesthesia. The 
sensations of touch, pain, temperature, 
and the muscular sense are all about 
equally affected. 

Ataxia is not uncommon, and may 
be a more striking symptom than the 
loss of power. All the reflexes are di- 
minished or lost, especially the knee-jerk, 
as the legs are usually most affected. 
Sometimes, particularly after diphtheria, 
there is loss of the knee-jerk, when there 
is no other symptom of neuritis. In the 
severe cases muscular tremor is frequent. 
Atrophy is a prominent symptom of 
neuritis, and it is evident early in the 
disease, often being quite as rapid as in 
poliomyelitis. The electrical reactions 
are altered, — every grade of reduction in 
the responses being seen, from a slight 
diminution in the reaction to faradism 
to the complete reaction of degeneration. Vaso-motor symptoms, such as 
oedema of the affected parts, glossiness of the skin, etc., are often present. 
Deformities from muscular contraction occur early ; they may be severe, 
and in some cases, permanent. 

Course and Prognosis. — The usual course of the disease is for the symp- 
toms gradually to increase for three or four weeks and then improve, 




Lipl 

theria in a child four years old. The 
position of the head and spine are 
due to partial paralysis of the trunk 
and neck. The legs were also af- 
fected. 



MULTIPLE NEURITIS. 789 

sometimes rapidly, but more often slowly, the case usually going on 
to complete recovery in the course of a few months. Exceptionally 
the paralysis may be permanent. The sensory symptoms always disap- 
pear before the motor ones. Multiple neuritis may prove fatal, from pa- 
ralysis of the heart or the muscles of respiration, or death may be due to 
asphyxia from the entrance of food or foreign bodies into the air passages, 
owing to anaesthesia of the epiglottis and paralysis of the muscles of 
deglutition. Death sometimes follows from complications, especially 
pneumonia. The electrical reactions are of much prognostic value in 
regard to the persistence of the paralysis. If the reaction of degeneration 
is present the paralysis is certain to last many months, and some muscles 
are sure to be permanently affected. Where there is simply a diminution 
in the faradic responses, even though accompanied by marked atrophy, 
complete recovery may be expected, although it is often slow. 

Diagnosis. — The diagnostic features of multiple neuritis are the com- 
bination of motor and sensory symptoms with the same distribution, the 
occurrence of atrophy, and the diminution in the electrical responses, even 
the reaction of degeneration. The gradual onset and the wide-spread 
distribution of the paralysis are also characteristic. If all four extremities 
are paralyzed, it is altogether the probable disease ; and if to this is added 
paralysis of the neck and spinal muscles, the diagnosis is almost certain. 
The facts that the paralysis is often incomplete, and that it involves parts 
distant from each other, are also important. It may be mistaken for 
poliomyelitis (page 776), for Landry's paralysis, or for Pott's paraplegia ; 
an important diagnostic point from the last mentioned is the condition 
of the reflexes, — being greatly exaggerated in Pott's paraplegia, while they 
are diminished or lost in multiple neuritis. 

Treatment. — As this disease tends in the great majority of cases to 
spontaneous recovery, it is difficult to estimate the value of any method 
of treatment. Causes, such as lead, arsenic, alcohol, and malaria, are to 
be sought and removed as the first step. During the acute stage the pais 
may be so severe as to require relief, which is best accomplished by the 
application of heat. In using counter-irritation care is necessary, and 
such active measures as cauterization should not be employed, for trouble- 
some ulceration may follow. After the acute stage has passed, oral the cud 
of three or four weeks, electricity should be begun, faradism being used if 
the muscles respond to a moderate current, otherwise galvanism. This 
should be continued daily until recovery. Strychnine is much used in 
these cases, but it is doubtful whether it has any specific influence, al- 
though as a tonic it is valuable. Other tonics, such as iron, quinine, 
and most of all cod-liver oil, should be given in every case. Massage is 
also beneficial. The special treatment of cardiac and respiratory paralysis 
will be discussed in the following article. 



790 DISEASES OF THE NERVOUS SYSTEM. 



DIPHTHERITIC PARALYSIS. 

This is not only the most frequent variety of multiple neuritis, but it 
has some peculiarities which make a separate consideration of it desirable. 

Frequency. — According to the statistics of various observers, paralysis 
including all varieties, occurs after diphtheria in from 5 to 15 per cent 
of the cases. Sanne gives 11 per cent in 2,448 cases; Lennox Browne, 14 
per cent in 1,000 cases ; the Eeport of the Collective Investigation by the 
American Pediatric Society, 9*7 per cent of 3,384 cases which were treated 
by antitoxine. 

It is as yet too soon to state to what degree the frequency of para- 
lytic sequelae after diphtheria is to be affected by the antitoxine treat- 
ment; but the figures above given would indicate that the protective 
power of the serum over the nervous tissues is not so great as is seen 
elsewhere, and that unless administered very early it may have little or no 
influence. 

Being one of the direct effects of the diphtheria toxine, neuritis is 
much more likely to follow severe than mild cases ; however, its occur- 
rence after some very mild attacks shows how great is the susceptibility 
of the nervous tissues to the action of this poison. Sometimes the throat 
symptoms have been entirely overlooked, and the development of paraly- 
sis has been the first thing to arouse a suspicion of previous diphtheria. 

Time of Occurrence. — During the second week, and sometimes even 
during the latter part of the first week, the early paralysis occurs, affecting 
the palate, and in some cases the heart. The most frequent and most 
characteristic paralysis — that affecting the throat, eyes, extremities, heart, 
or respiration — begins at a later period, usually from one to three weeks 
after the throat has cleared off, and sometimes even later than this. 

Extent and Distribution of the Paralysis. — Eoss * gives the following 
statistics of 171 collected cases of diphtheritic paralysis : Palate affected 
in 128 ; eyes in 77, in 54 of which the muscles of accommodation were 
involved ; lower extremities in 113 ; upper extremities in 60 ; trunk or 
neck in 58; muscles of respiration in 33. I do not think this repre- 
sents the actual frequency of the different varieties so truly as do the 
American Pediatric Society's figures, which give the forms of paralysis 
noted in a series of cases collected for another purpose. In 328 cases of 
paralysis, the variety was mentioned in 189 : in 124 the throat was af- 
fected ; in 22 the extremities ; in 11 the eyes ; in 5 the muscles of respi- 
ration ; in 32 the heart ; in 1 the neck only ; in 8 the paralysis was 
"general." 

Symptoms. — In the great majority of cases the throat is affected, and 
usually the paralysis is first noticed there. It may involve the palate 

* The Medical Chronicle, December, 1890. 



DIPHTHERITIC PARALYSIS. 791 

alone, or the muscles of the pharynx or larynx in addition. The muscles 
of the extremities or of the eye are often next attacked. In severe 
cases there may also be involved the muscles of the trunk and neck, and 
sometimes the diaphragm. Cardiac paralysis not infrequently occurs 
where no other parts have been previously affected, but in nearly all the 
other forms, the throat symptoms precede. It is this which distinguishes 
diphtheritic paralysis from other forms of multiple neuritis. Whatever the 
extent or situation of the paralysis, the knee-jerk is nearly always lost. The 
symptoms in the extremities and the trunk do not differ from those of 
multiple neuritis from other causes. The throat paralysis shows itself by 
a nasal voice and by regurgitation of fluids through the nose, sometimes 
by difficulty in swallowing or the entrance of food into the larynx, owing 
to anaesthesia of the epiglottis and paralysis of the muscles of deglutition. 
There may be difficulty in protruding the tongue or in articulation. 
Paralysis of the vocal cords may cause hoarseness, aphonia, or attacks of 
spasmodic dyspnoea. Facial paralysis is very rare. On the part of the 
eye there is most frequently seen inability to read, owing to paralysis of 
the muscles of accommodation ; there may be dilatation of the pupils, 
rarely strabismus or ptosis. 

Next to that of the throat, paralysis of the muscles of respiration and the 
heart are the most characteristic forms of diphtheritic neuritis. Respir- 
atory paralysis may be due to involvement of the phrenic or the intercostal 
nerves, most frequently the former. Extensive paralysis of other parts — 
the throat, extremities, or trunk — usually precedes. The first warning is 
generally in the form of occasional attacks of dyspnoea, sometimes ac- 
companied by cough. Gradually these attacks increase in frequency and 
severity. The voice is reduced to a whisper. As the diaphragm is usu- 
ally affected, the breathing is entirely thoracic. The respiratory move- 
ments are rapid, but irregular, shallow, and ineffectual. There is cyanosis, 
also great subjective as well as objective dyspnoea. The anxiety, distress, 
and apprehension of the patient are sometimes terrible. There is a con- 
stant dread of impending suffocation, and the respiratory movements are 
continued only by the patient's constant efforts, otherwise they may cease 
altogether. After a few hours these severe symptoms may subside, to re- 
turn after a short respite. There may be several such attacks during two 
or three days, in each of which death seems imminent. Unfortunately, this 
is the most frequent termination. Of thirty-three such cases collected by 
Ross, only eight recovered. Associated with these respiratory symptoms 
others may be present, indicating that the pneumogastric ifi involved. 
There may be attacks of abdominal pain, vomiting, and disturbance of 
the heart's action, — usually an irregular or intermittenl pulse, which may 
be either unnaturally slow or very rapid. In many cases bhe hearl con- 
tinues to beat normally, even though the respiration is bo much disturbed. 

The premonitory symptoms of cardiac paralysis are an irregular or 



792 DISEASES OF THE NERVOUS SYSTEM. 

intermittent pulse, often slow, but becoming very rapid from even the 
slightest exertion. It is always weak and compressible. The first sound 
of the heart is feeble and may be reduplicated. As the symptoms increase 
there are marked pallor, coldness of the extremities, great restlessness, 
anxiety, precordial distress, and perhaps orthopnoea. Within twenty-four 
hours from the beginning of such symptoms death usually occurs. In other 
cases it may come suddenly without any warning, or with a warning so 
slight as to be overlooked. At such times it often follows some muscular 
exertion, such as getting out of bed, walking across the room, or so slight 
an effort as sitting up suddenly in bed. Fits of temper or other excite- 
ment have at times produced it. It is by no means certain that sudden 
heart paralysis is always due to a lesion of its nerves. A not less impor- 
tant cause is toxic myocarditis. In the cases where death occurs sud- 
denly without premonition after some muscular effort, it is in all prob- 
ability the heart muscle which is most at fault. However, in many cases 
the two conditions are associated. 

Death from diphtheritic paralysis is usually due either to cardiac or 
respiratory paralysis. Of one hundred and seventy-one cases of all va- 
rieties collected by Eoss, forty-five were fatal. 

Treatment. — Cases of paralysis of the trunk or extremities are to be 
managed like others of multiple neuritis. In severe forms of throat 
paralysis feeding by a stomach tube should always be employed, on ac- 
count of the danger of the entrance of food into the air passages. It 
must in most cases be continued for several days. The tube may be 
passed either through the mouth or the nose. 

The great mortality attending paralysis of the heart and respiration 
shows how unsuccessful is treatment in most of the cases ; still, no doubt 
there are instances where life may be saved by judicious treatment. In 
cases of threatened heart paralysis, the drug most to be depended upon 
is morphine, hypodermically ; this should be used every two or three hours 
in sufficient doses to keep the patient under its influence while threat- 
ening symptoms are present. In some cases it may be advantageously 
combined with strychnine. The patient should be kept absolutely quiet, 
not even being allowed to turn in bed. In respiratory paralysis the gen- 
eral reliance is upon strychnine used hypodermically in doses sufficient 
to produce its physiological effects, and upon faradization of the respira- 
tory muscles, particularly the diaphragm. Faradism is to be used in 
the attacks of respiratory failure and continued while they last. In some 
cases patients may by these means be tided over the dangerous stage of the 
disease. 

FACIAL PARALYSIS. 

Peripheral paralysis of the face occurring as a result of injury inflicted 
during delivery has already been described (page 108). There remain to 



FACIAL PARALYSIS. 



793 




be considered here cases which arise from causes that operate at a later 
period. The facial nerve may be affected in any one of three situations, — 
after its exit from the cranium,* in the bony canal, and within the cranium. 

In the first situation, the principal cause of neuritis is exposure to cold 
(the " rheumatic " cases), but it occasionally occurs as a complication of 
mumps and disease of the lymph glands of this region. The nerve is af- 
fected just after it has escaped from the stylo-mastoid foramen, and all the 
branches given off beyond its exit are involved. There is paralysis of the 
muscles of the forehead, those about the eye, the cheek, nose, and mouth. 
The affected side of the face is smooth, there is inability to wrinkle the 
forehead, contract the eyebrows, close the eye completely, raise the nos- 
tril, whistle or blow. The mouth is 
drawn to the affected side (Fig. 140). 
If the paralysis is complete, there may 
be difficulty in drinking or in articula- 
tion. In partial paralysis the symp- 
toms may not be noticeable while the 
face is at rest. There are no sensory 
symptoms. The electrical reactions 
resemble those of other forms of neu- 
ritis ; there is diminution in the re- 
sponse to the faradic current, which 
is more or less marked according to 
the severity of the lesion, and there 
may be the reaction of degeneration. 

In the bony canal, the facial nerve 
is usually inflamed as a result of dis- 
ease of the ear. In children this is 
much more frequent than from the 
causes just mentioned. While it is 

possible for it to occur in acute cases, it generally accompanies chronic 
otitis, especially where there is caries of the petrous bone. In addition to 
the paralysis there is present or there is a history of a discharge from 
the ear, and generally there is some deafness upon the side affected. The 
facial symptoms are usually the same as in the cases first described. 
However, when the nerve is affected between the stapedius and the genic- 
ulate ganglion, there is a disturbance of the sense of taste, and of the 
secretion of the saliva. 

At the base of the brain the trunk of the nerve may be involve! in 
cerebral tumour, basilar meningitis, and in fracture of the skull. Id any 
of these conditions the auditory nerve also is likely to be affected. 

Prognosis. — The result is greatly modified by the cause in the dif- 
ferent cases. In those which are due to cold, spontaneous recovery 
usually occurs in the course of a few weeks or months. In those depend- 






Fio. 140. — Facial paralysis from middle- 
ear disease in a child two and a half 
years old. 



794 DISEASES OF THE NERVOUS SYSTEM. 

ing upon disease of the ear, the outlook is not so favourable, and though 
there may be improvement, it is not rare for some paralysis to be per- 
manent. In the third group of cases, facial paralysis is only one of the 
symptoms, and the result depends entirely upon the nature of the cause. 

Diagnosis. — Facial paralysis is easily recognised. It is important to 
separate the peripheral paralysis from that due to a lesion above the 
pons, as in cases of ordinary hemiplegia. In the latter group only the 
lower half of the face is affected, the muscles of the forehead and those 
about the eye escaping, and the electrical reactions are unchanged. 

Treatment. — This is essentially the same as in other cases of neuritis. 
In cases due to ear disease the primary lesion should receive appropriate 
treatment. 



SECTION VIII. 
DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

CHAPTER I. 

DISEASES OF THE BLOOD. 

In" general, the blood in infancy and childhood, as compared with that 
of adult life, is thinner and contains a larger proportion of water ; it is 
also poorer in solids and has a lower specific gravity. . 

Specific Gravity. — This has no constant relation to the number of 
white or red corpuscles, but varies with the amount of haemoglobin. The 
highest specific gravity is seen in the blood of the newly-born, when, 
according to Lloyd-Jones, it is 1*066. During the first two weeks of life 
it sinks rapidly to its lowest point — 1*048 to 1-052 — where it remains 
until about the end of the second year ; after this time it rises gradually 
until about puberty. The average specific gravity during childhood is 
1-052 to 1-055 (Hock and Schlesinger). 

Haemoglobin. — The percentage of haemoglobin is highest in the blood 
of the newly-born, and falls rapidly during the first few days after birth. 
Throughout childhood it is considerably lower than in adult life. The 
haemoglobin is lowest between the third month and the fifth year ; after 
the fifth year it gradually increases up to puberty. According to Wydo- 
witz, the usual range in infants and young children, as measured by the 
adult standard, is between 60 and 80 per cent, 60 per cent being the lowest 
limit in healthy children. 

The cells of the blood are the red corpuscles or erythrocytes, and the 
white corpuscles or leucocytes. 

Red Corpuscles. — The number of red corpuscles is highest in the newly- 
born. At this time it is from 4,350,000 to 6,500,000 in each cubic milli- 
metre. In infancy it is from 4,000,000 to 5,500,000; in later childhood, 
from 4,000,000 to 4,500,000 (Hayem). In size a much greater variation 
is seen in the red cells of the newly-born than in those of older children 
and adults. In the blood of the foetus there are present nucleated red 
corpuscles or erythroblasts (Plate XVI, A, 5, and B, 2). Tins.- diminish 
in number toward the end of pregnancy. They arc always found in the 
blood of premature infants, but in infants born at term they are seen only 

70.", 



796 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

in small numbers and disappear after a few days. In later infancy their 
presence is always pathological. 

White Corpuscles. — Of these, five different varieties are distinguished 
by Ehrlich : 

1. Lymphocytes or small mononuclear cells (Plate XVI, A, 6). These 
resemble the red blood-cells in size, and have a single deeply staining 
nucleus, which is so large as nearly to fill the cell body ; the protoplasm 
is non-granular. The source of these cells is believed to be the lymph 
glands. 

2. Large mononuclear cells. These are much larger than the preced- 
ing variety, and have a single large ovoid nucleus with quite a broad 
margin of protoplasm surrounding it. They are not numerous in normal 
blood ; they are derived from bone-marrow and the spleen. 

3. Mononuclear transition forms. These are derived from the va- 
riety last mentioned, being similar in size and colour. The nucleus shows 
an indentation on one side — the beginning of a nuclear division. When 
further developed, these cells show traces of neutrophile granulations in the 
protoplasm, usually between the horns of the nucleus. 

4. Poly nuclear cells with neutrophile granulations (Plate XVI, A, 3). 
The nucleus is long, irregular, and twisted in various shapes or divided 
into several parts. The protoplasm contains fine granulations affected 
only by stains of neutral reaction. These cells are smaller than the mono- 
nuclear forms from which they are derived, although somewhat larger 
than the red cells. They constitute the largest proportion of the leuco- 
cytes in normal blood, and they are the only forms increased in ordinary 
leucocytosis. Forms 2, 3, and 4 probably represent different degrees of 
development of the same cells.* 

5. Eosinophile cells (Plate XVI, A, 1). These are not related to any 
of the preceding forms. The protoplasm contains large fat-like granula- 
tions, which can be seen even before staining. They stain readily with 
acid colors, especially with eosin, from which peculiarity their name is 
derived. The granulations of these cells are much coarser than those of 
the polynuclear neutrophile cells, while their nuclei, of which there are 
generally two or three, do not stain so darkly. After the eosinophile cells 
have broken down, the resulting granulations somewhat resemble groups 
of cocci. In normal blood these cells form but a small proportion of 
the leucocytes. 

The number of leucocytes in the blood of the newly-born is three or 
four times that of the adult, being on the average 18,000 per cubic milli- 
metre (Hayem). The variations during later childhood are from 6,000 to 
12.000. 



* In Uskow's classification these are derived as " ripe " and " over-ripe " cells from, 
the lymphocyte, which is regarded as the young or " unripe " cell. 



PLATE XVI. 



Fig- A. 




Fig.B. 
A. The Blood in Leuojbmia. 

1, Eosinophil cells ; 2, myelocytes: 8, polynuolear aeutrophile cells; 4, red eells; 
5, nucleated red cells; 6; lymphocytes. 

B. Pernicious Anemia. 

1, Megaloblasts ; 2, nucleated megaloblasts ; 3, a polynuclear neutrophil cell 
4, poikilocytes. (After Monti and Berggrttn.) 



SIMPLE ANAEMIA. 797 

The white cells may be said to be increased — i. e., leucocytosis exists — 
when their proportion to the red cells is greater than 1 to 200. It is not 
yet possible to state the exact percentages of the different varieties of white 
cells in normal blood. The polynuclear cells are, however, the most nu- 
merous, the lymphocytes next, and the eosinophile cells least frequent. 

Before leaving the subject of the cells of the blood the so-called 
blood- shadows deserve a brief mention. These, according to Silbermann, 
are common in the blood of the newly-born, but diminish with the age of 
the child. They contain no haemoglobin. The existence of such cells is 
denied by some observers, who regard the appearance as due to the prepa- 
ration of the specimen. 

The following are the principal peculiarities in the blood of the 
newly-born : The specific gravity and the haemoglobin are high. The 
number of red cells is considerably higher than the average during child- 
hood, and the same is true to a less degree of the leucocytes. The red 
cells vary much in size. They show less tendency to form rouleaux, al- 
though this is denied by some observers. Nucleated red cells, erythroblasts, 
are found for a day or two in small numbers, and the blood-shadows of 
Silbermann may be present. 

It is only within the last few years that the diseases of the blood 
have been studied with anything like scientific accuracy. With our pres- 
ent knowledge it is difficult to classify accurately the various forms of 
anaemia. The essential character and the relation of the different forms 
to one another, are matters upon which there is still much difference of 
opinion among good observers. The classification here presented is that 
which has received the most general adoption, and may be accepted as a 
provisional one. With reference to the nicer points, most of the obser- 
vations made prior to 1885 must be taken with considerable allowance. 

SIMPLE ANEMIA. 

This consists in an impoverishment of the blood, especially the red 
cells, and a corresponding diminution in the specific gravity and in the 
amount of haemoglobin. It is essentially a secondary anaemia, and occurs 
apart from disease of the blood-making organs. The important factors in 
its etiology are, first, an insufficient production of blood in consequence of 
deficient food or interference with the absorption of food, and, second, an 
increased drain or destruction of blood, as. in exhausting diseases. In- 
fancy and childhood are themselves strong predisposing causes of anaemia, 
on account of the great demands made upon the blood in the rapid growth 
of the body. 

Etiology.— In certain cases anaemia may be congenital, as in infants 
born of delicate or anaemic parents, or where the mother during pregnancy 
has suffered from some serious disease, such as syphilis or nephritis. Ac- 
quired anaemia may come on at any period in infancy or childhood. The 



798 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

cause may be loss of blood, as in haemorrhages of the newly-born, epistaxis, 
purpura, scurvy, or haemophilia. None of these are very common etio- 
logical factors. More frequently anaemia depends upon a loss of albumin 
of the blood, as in prolonged suppuration, chronic nephritis, large serous 
effusions occurring in the course of cardiac disease, certain forms of diar- 
rhoea, and in malignant disease. Very frequently also it depends upon 
improper food, or disease of the organs of digestion or assimilation, as in 
the various forms of chronic diarrhoea, ileo-colitis, or chronic indigestion. 
These cases form a group sometimes classed as anaemia from inanition. 
In infancy, unhygienic surroundings, bad air, and close confinement to 
unhealthy apartments, are important factors in producing anaemia. In a 
large number of cases the anaemia is of toxic origin. In this group may 
be classed not only cases in which anaemia depends upon mineral poisons 
introduced into the body, such as mercury or chlorate of potassium, but 
also the poisons of all the infectious diseases, notably diphtheria. Febrile 
anaemia is not entirely due to toxic causes. It depends in part, no doubt, 
upon interference with digestion and assimilation. Anaemia may be due 
to parasites in the blood, the most striking illustration being the Plasmo- 
dium malariae, and it may occasionally arise from some forms of intestinal 
worms. The etiology of the anaemia accompanying certain constitutional 
diseases, such as rickets, tuberculosis, or rheumatism, is of a complex 
character. 

Symptoms. — One of the most striking symptoms is the pallor of the 
skin and mucous membranes, although this is by no means an infallible 
guide to the degree of anaemia. Such children usually exhibit also symp- 
toms of malnutrition : their muscles are soft and flabby ; they are fre- 
quently thin and poorly nourished, but occasionally have an unusual 
amount of fat. They almost invariably suffer from digestive disturbances, 
such as coated tongue, poor appetite, and constipated bowels. The ex- 
tremities are often cold, the pulse is rather weak and often slightly irregu- 
lar. The heart-sounds are feeble, and. anaemic murmurs may be heard 
either over the heart or the large vessels even in infancy, and occasionally 
a venous hum may be heard in the neck. In a certain number of cases 
of moderate severity there is found enlargement of the spleen, but rarely 
to the degree seen in leucaemia, or in the pseudo-leucaemia of infants. 
These cases were formerly classed separately as " splenic anaemia." 

Nervous symptoms are frequent. Anaemic children are fretful, irrita- 
ble, and often exhibit a degree of nervousness amounting almost to chorea. 
Others complain of headache and indefinite pains. Sleep is restless and 
disturbed, and often there is insomnia. The urine is scanty, frequently 
pale, and in many cases contains an excess of uric acid ; there may be 
enuresis. Such children are easily fatigued, they frequently suffer from 
shortness of breath upon exercise, and occasionally have fainting attacks. 
They are especially prone to chronic catarrhal inflammations of the nose, 



CHLOROSIS. 799 

pharynx, and bronchi. Epistaxis is not an uncommon symptom. Leu- 
corrhoea may be present even in girls of three or four years. Dropsy is 
not infrequent in infants, but is rather more common in older children. 
In infancy, if anaemia comes on rapidly, as in the course of diarrhoeal dis- 
eases, cerebral symptoms may be present. 

The blood. — The changes in the blood depend much upon the grade 
of anaemia. In the milder forms there is only a moderate diminution in 
the specific gravity (1*042 to 1*046), in the haemoglobin (50 to 55 per cent), 
and in the number of red cells, with very slight changes in their form or 
size. There is no increase in the leucocytes, although they are relatively 
more numerous on account of the reduction in the number of red cor- 
puscles. 

In more severe cases the haemoglobin may be reduced to 30 or even 20 
per cent, the specific gravity to 1*038 or lower, and the number of red 
cells to less than half the normal. In cases of such severity quite marked 
changes are usually present in their size and form. Microcytes, megalo- 
cytes, poikilocytes, and nuclear red cells (Plate XVI) may be present. 
The leucocytes in many cases show only a relative increase ; in others 
they are actually increased, and may be twice as numerous as normal. 
Cases of this severity are to be considered, according to Monti and Berg- 
griin, as intermediate between simple and pseud o-leucaemic anaemia. 

Prognosis. — The course and termination of anaemia depend upon its 
cause. If this can be removed, steady improvement and recovery may be 
expected. In extreme cases death may take place, but rarely from the 
anaemia, usually from some complicating disease. 

In making a prognosis there must be considered not only the general 
symptoms and the cause of the anaemia, but also the condition of the 
blood. If there is only a moderate reduction of the haemoglobin and in 
the number of the red cells, with slight changes in their form and with no 
increase in the leucocytes, the prognosis is good. If the haemoglobin is 
reduced below 30 per cent, if the number of red cells is less than half 
the normal, and marked changes in form are present, with or without 
great increase in the actual number of leucocytes, the prognosis is less 
favourable. 

The treatment of all the forms of anaemia will be considered together 
at the close of the chapter. 

CHLOROSIS. 

Chlorosis is a primary or essential anaemia which usually occurs ra 
young girls about the time of puberty. It is characterized by a peculiar 
greenish-yellow tint of the skin, and is not accompanied by emaciation. 
The changes in the blood consist in a very great reduction in the hemo- 
globin without a corresponding diminution in the red corpuscles. 

Etiology. — The exact cause of chlorosis is not yet fully understood. 



800 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

The disease rarely occurs in males, the great majority of the cases being 
in girls between the fourteenth and seventeenth years, and more often in 
blondes than in brunettes. Heredity appears to be a factor in a consider- 
able number of the cases. Among the other causes may be mentioned 
occupations deleterious to health, such as employment in factories or con- 
finement in ill-ventilated rooms; insufficient food or clothing; psychical 
disturbances, like grief, care, or fright ; excessive mental or physical 
strain ; and disorders of menstruation — although the latter are perhaps 
more frequently a result than a cause of the disease. Virchow first called 
attention to the fact that chlorosis might depend upon a congenital nar- 
rowing of the aorta, sometimes associated with a small heart. It is difficult 
to reconcile this etiology with the rapid recovery under appropriate treat- 
ment which is seen in most of the cases. Andrew Clark has advanced 
the view that the chief cause of chlorosis is constipation and the resulting 
absorption of toxic materials from the intestine. The intestinal origin of 
the disease has been lately urged with a good deal of force by Forchheimer. 

Lesions. — Chlorosis is rarely fatal. In the few fatal cases the lesions 
noted have been dilatation of the right heart with hypertrophy of the left 
ventricle, a small aorta, small uterus and ovaries, and occasionally round 
ulcer of the stomach. Under the microscope there may be found a very 
marked degree of fatty degeneration of the heart muscle, and sometimes 
of the inner coat of the blood-vessels. 

Symptoms. — The general symptoms of chlorosis are very like those of 
simple anaemia. There are observed shortness of breath upon exercise, 
palpitation, syncope, attacks of vertigo, disturbances of digestion, amenor- 
rhcea, and almost invariably constipation. The appetite is capricious, it 
being a peculiarity of these patients to crave all sorts of indigestible 
articles. Instead of the usual pallor of anaemia, the skin has a yellowish- 
green tint, from which the term " green-sickness " has arisen. Occasion- 
ally patches of pigmentation are seen. Anaemic cardiac murmurs may be 
heard in various situations, most frequently a systolic murmur at the base 
of the heart, and usually loudest over the pulmonic area. There may be a 
venous hum in the neck. In some marked cases there is evidence of slight 
cardiac dilatation, especially of the right heart, and there may be hyper- 
trophy of the left ventricle. The pulse is weak and soft, oedema of the 
feet is frequent, and sometimes there is slight albuminuria. In some cases 
there is fever. Nervous disturbances, such as vague, indefinite pains, at- 
tacks of migraine, supra-orbital neuralgia, various hysterical manifesta- 
tions, and chorea, are common. Ulcer of the stomach is sometimes seen 
as a complication. 

The blood. — The blood changes in chlorosis are quite constant. The 
red corpuscles may be normal or but slightly diminished in number. In 
many cases but little variation from the normal size is seen ; in others 
there are microcytes, megalocytes, and poikilocytes. The red corpuscles 



PSEUDO-LEUC^EMIC ANAEMIA OF INFANCY. 801 

have an unusually pale colour. The number of leucocytes is normal or 
very slightly increased. The haemoglobin is uniformly reduced, usually to 
a great degree. Osier gives 44T per cent as the average in forty cases. 

Prognosis. — The course of the disease is essentially a chronic one, 
often lasting for a year. Relapses are quite frequent. -Except when de- 
pendent upon congenital malformations of the heart and blood-vessels, 
these cases regularly recover when proper treatment can be carried out. 
A small number prove fatal by the development of tuberculosis or the 
occurrence of gastric ulcer. 

Diagnosis. — The diagnosis is in most cases easily made from the etiol- 
ogy, the functional derangement of the heart, the colour of the skin, and 
a positive diagnosis always by an examination of the blood. 

PSEUDO-LEUCJEMIC ANEMIA OF INFANCY. 

This form of anaemia was first described by Von Jaksch in 1889, and is 
believed to be peculiar to infants and young children. It is characterized 
by marked leucocytosis, marked reduction in the number of red corpuscles 
and in the haemoglobin, a great enlargement of the spleen, and sometimes 
a moderate enlargement of the liver and the lymphatic glands. This 
disease is not to be confounded with the pseudo-leucaemia of adults, or 
Hodgkin's disease, which is purely a disease of the lymphatic glands with 
secondary anaemia, but without any leucocytosis. 

Etiology. — Of the cases thus far recorded the majority have been 
between the ages of seven and twelve months, the oldest being at three 
and a half years. Of twenty cases collected by Monti and Berggriin,* six- 
teen showed evidences of rickets and one was syphilitic. Pseudo-leucaemia, 
however, appears to occur in this disease only when the splenic enlarge- 
ment has reached a certain grade. The exact cause of the disease is still 
unknown, and its essential nature is a matter of some doubt. Monti be- 
lieves that it may develop from the more severe cases of anamiia which 
are accompanied by leucocytosis, as he has observed this condition before 
the development of pseudo-leucaemia and during its subsidence. The 
disease may terminate in ordinary leucaemia, and possibly in pernicious 
anaemia. 

Lesions. — The most characteristic change is found in the spleen. This 
organ is very much enlarged, often forming an abdominal tumour, which 
extends as low as the crest of the ilium and as far forward aa the umbili- 
cus. It is firm, hard, the surface appears somewhat wrinkled, and there 
may be evidences of perisplenitis. The microscope shows an increase of 
cellular elements, a few cells containing h»moglobin ( Luzet). Enlargement 
of the liver is less constant, it being norma] in more than half the oases. 
There is no relation between the size of the spleen and that of the liver. 



* Die chronische Aniimic im Kindesalter, Leipsic, 1893. 

GO 



802 DISEASES OP THE BLOOD, LYxMPH NODES, BONES, ETC. 

The hepatic cells are unchanged. Enlargement of the lymph glands has 
been noted in about half the reported cases, the swelling affecting the 
cervical, axillary, or inguinal glands ; but it is rarely great. A moist ap- 
pearance and a diffuse redness of the bone-marrow have been described 
by Luzet, the changes being usually most marked about the epiphyses. 

Symptoms. — The blood. — The number of reported cases is as yet too 
small to make positive statements possible upon all points. The most 
constant features noted thus far are the following : 

The specific gravity is lowered, the usual range being between 1*035 and 
1044. The reduction of the haemoglobin is very great ; in many of the 
cases it has been as low as 30 per cent, and in a few below 25 per cent. The 
leucocytes are increased in number, this being one of the striking features 
of the disease. In ordinary cases the proportion of leucocytes to red cor- 
puscles is 1 to 100 or 1 to 75. In severe cases the proportion may be as 
high as 1 to 20 or even as 1 to 12. All the usual varieties of leucocytes 
are seen, the proportions of these varying much in the different cases. 
The red corpuscles are reduced in number in proportion to the severity 
of the disease, usually to from 65 to 75 per cent, but they may be as low 
as 35 or even 25 per cent. In six of twenty cases the actual number was 
below 1,600,000 (Monti and Berggriin). More characteristic than any of 
the above features are the changes in the appearance of the red cells. 
Very marked inequality in their size and shape is seen in most of the 
cases. Many microcytes are present ; also great numbers of nuclear 
red blood-cells (erythroblasts), normoblasts, and megaloblasts with divid- 
ing nuclei. These are seen to some degree in other forms of anaemia, 
particularly in the pernicious variety and in the severe types of simple 
anaemia, but they are more abundant in pseudo-leucaemia. The larger the 
proportion in which they are present the worse the prognosis. Finally, 
there is occasionally seen a division of the nuclei of the red cells (karyo- 
kinesis), regarded by some as characteristic of the disease, although this 
is not admitted by all. 

The general symptoms of the disease develop slowly and with the 
usual signs of anaemia. In some cases the infants continue to be plump 
and well nourished. Pallor is usually very marked. Enlargement of the 
spleen is so great that it can hardly be overlooked if the abdomen is ex- 
amined. The glandular enlargements are not marked, and in many cases 
are wanting altogether. 

The course of the disease is essentially chronic. Cases have been seen 
in which pseudo-leucaemia developed from an ordinary severe simple 
anaemia in the course of a few weeks. The symptoms and blood changes 
generally come on slowly in the course of weeks or months, and sometimes 
remain nearly stationary for as long a period as several months, aud then 
slowly improve. In other cases they grow gradually worse, and the 
changes in the blood come to be the same as in ordinary leucaemia. Some 



PERNICIOUS ANJEMIA, 803 

observers are inclined to believe that the disease is really an early stage of 
leucaemia, which does not reach its full development because the children 
succumb too early. In the cases going on to recovery, there is noticed 
improvement in the general symptoms coincident with a diminution in 
the size of the spleen, a reduction in the number of leucocytes, an increase 
in the red corpuscles, the haemoglobin, and the specific gravity, and a 
gradual disappearance of the erythroblasts. 

Prognosis. — In Monti's list of twenty cases four proved fatal ; one re- 
covered, in which the proportion of leucocytes to the red corpuscles had 
been 1 to 12. The prognosis should always be guarded, for, although 
improvement may take place, patients are very apt to be carried off by 
intercurrent disease. 

Diagnosis. — The diagnosis is to be made from simple anaemia with 
leucocytosis, and from leucaemia. In simple anaemia the leucocytosis is 
not so great, and it is not accompanied by such a degree of splenic enlarge- 
ment. In leucaemia the reduction in the red cells and in the haemoglobin 
is very rarely as great as in pseudo-leucaemia. 

PERNICIOUS AlOEMIA. 

This is the most severe form of anaemia known. Its cause and essen- 
tial nature are as yet very imperfectly understood. It is characterized 
by quite uniform blood changes and by the general symptoms of a very 
marked anaemia, and it tends to go on from bad to worse, terminating 
fatally in the great proportion of cases. 

Etiology. — Pernicious anaemia is a rare disease in childhood, and espe- 
cially rare in infancy. In the cases which have been observed in early 
life the following etiological factors have been noted : It has been associ- 
ated with hereditary syphilis and with severe rickets, especially when ac- 
companied by a marked enlargement of the spleen. It has followed other 
diseases, especially grave disturbances of nutrition. Sometimes simple 
anaemia, when severe and of long standing, has gradually developed into 
the pernicious type. In a few instances parasites, particularly tapeworms, 
have been the cause. Pernicious anaemia has in some instances occurred 
in patients where no cause whatever could be assigned. 

Many theories have been advanced in explanation of pernicious ane- 
mia. The one which at present appears to have most in its favour is that 
the disease consists in a great destruction of the red blood-cells, particu- 
larly in the liver, and that this is brought about through the agency oi 
some poison or poisons taken up from the intestine by the portal circula- 
tion.* This has been advanced by Hunter and others in explanation of 
the peculiar deposit of iron found in the hepatic cells. 



* For fuller discussion of this theory of pernicious anaemia, see Griffith and Burr, 

the Medical News, October 17, 1801. 



804 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

Lesions. — There is found a very high grade of anaemia in all the in- 
ternal organs, fatty degeneration of the heart and blood-vessels, and some- 
times also of the liver and kidneys, with numerous capillary haemorrhages 
in the various organs. The most characteristic post-mortem change, 
however, according to Hunter, consists in the deposit of iron in the 
hepatic cells. Its distribution is peculiar and unlike that seen in any 
other disease. 

Symptoms. — The blood. — Both the specific gravity and haemoglobin 
are much reduced, the latter usually below 25 per cent, and in several* 
instances below 15 per cent, but the percentage is still distinctly greater 
than that of the red cells. One of the most striking changes is the great 
reduction in the number of the red blood-corpuscles, the number of which 
is lower than in any other form of anaemia, the reduction being greater 
than in the haemoglobin. Very often the number has been reduced below 
500,000 in a cubic millimetre. Marked inequality is seen in the distribu- 
tion of the haemoglobin in the red corpuscles, some being almost colour- 
less while others are deeply stained. There is great variety in the size 
and form of the red cells, this generally being proportionate to the severity 
of the disease. There are found microcytes and poikilocytes, but espe- 
cially characteristic is the large number of macrocytes. There are many 
nuclear red blood-corspucles, both normoblasts and megaloblasts (Plate 
XVI, B). The reduction in the number of the leucocytes is usually in 
proportion to that of the red corpuscles. This is a peculiar feature of 
this disease (Monti and Berggriin). In most of the other conditions at- 
tended by reduction in the number of red cells the leucocytes are relatively 
increased. 

The general symptoms are those of a most intense anaemia. There is 
marked pallor of the skin and mucous membranes, with great weakness 
and prostration. Various anaemic heart murmurs are heard. There is 
dyspnoea, and usually the urine is scanty and of low specific gravity. 
There may or may not be emaciation. The late symptoms are haemor- 
rhages from the nose and other mucous membranes, subcutaneous ecchy- 
moses with dropsy of the feet and ankles, and sometimes of the large 
serous cavities of the body, but without albuminuria. In many cases fever 
is present. This may be so high as to lead to the suspicion of some acute 
infectious process. 

The course of the disease is chronic, it being in most cases several 
months. In some, however, the progress is so rapid that death may occur 
within two or three months from the beginning of marked symptoms. 
As a rule, the symptoms are steadily progressive until death occurs ; the 
only exceptions being the cases in which the disease depends upon some 
intestinal parasite ; here improvement and even recovery may occur. 

Diagnosis. — This is to be made from other forms of anaemia only by 
the blood examination ; the most important points with reference to red 



PERNICIOUS AXJEMIA. 805 

corpuscles are the great reduction in their number, the unequal distribu- 
tion of haemoglobin, the marked irregularities in form and shape, and the 
presence of many large nuclear forms ; with reference to the leucocytes, a 
reduction in number proportionate to that of the red cells. 

Treatment of the Different Forms of Anaemia. — In secondary ancemia 
the thing of the first importance is to discover and treat the primary 
condition upon which the anaemia depends. In infancy, special attention 
should be given to diet and hygiene, particularly with reference to an 
abundant supply of fresh air. The whole manner of life of these patients 
must be carefully studied and managed according to the directions laid 
down in tlie chapter upon Malnutrition, with which condition, especially 
in infancy, a very large number of these cases are associated. The general 
treatment referred to is often more important than the administration of 
the preparations of iron, which, however, should never be omitted. 

The preparations of iron available for infants are the Drees's albumi- 
nate, the pepto-manganate (Gude), the bitter wine, the malate and the 
citrate. The dose should be regulated according to the age of the child. 
Older children may take the same preparations as adults, especially Blaud's 
pills. Much benefit is seen from combining arsenic with iron, or from 
alternating the two. Arsenic should be used in conjunction with iron in 
every anaemia in which there is enlargement of the spleen or lymphatic 
glands. In addition to these remedies, cod-liver oil should be given 
throughout the entire cold season. 

In chlorosis more decided results are seen from the use of iron than 
in any other form of anaemia. Blaud's pills are here the favourite method 
of administration, and are advantageously combined with small doses of 
nux vomica and aloin to overcome the tendency to constipation. Arsenic 
is useful in these cases also. Great benefit in chlorosis results from 
change of air and change of scene, thus removing the patient from all 
sources of nervous excitement or disturbance. The general condition, 
diet, and habits of life should also receive careful attention, particularly 
the condition of the bowels. The use of oxygen is a valuable adjuvant in 
the treatment of cases not yielding to iron alone. It is important that the 
administration of iron should be continued for several months after the 
disappearance of all symptoms, on account of the tendency to relapses. 

In the pseudo-leuccemic anosmia of infants, arsenic is decidedly the 
most valuable drug, but should be given in combination with iron. 
Fowler's solution is the best preparation for infants; the dose should 
rarely be more than one drop, which should be repeated four or five 
times daily after feeding, and continued for a long time. The general 
treatment of these patients is the same as in cases of simple anaemia. 
When rickets is present cod-liver oil and phosphorus Bhould be added. 

In pernicious anaemia, arsenic offers a much better prospect of im- 
provement than iron. Beginning with small doses, the amount Bhould be 



806 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

gradually increased up to the point of tolerance, very much as in cases of 
chorea. 

In every case of anaemia the most careful attention should be given to 
the general condition, particularly guarding against exposure to cold and 
dampness. The feeble circulation of these patients renders them pecul- 
iarly susceptible. Caution should also be given against much muscular 
exercise. With a severe grade of anaemia very active exercise should be 
prohibited, and many of these patients do best when complete rest in bed, 
either for the entire time or for a considerable part of each day, is in- 
sisted upon. This applies to children of all ages. 

LEUCAEMIA. 

This is a disease in which the essential feature is a great increase in 
the number of leucocytes, with a moderate reduction in the number of 
red corpuscles, and the presence in the blood of cellular forms not found 
in other diseases. 

Etiology. — Leucaemia is a rare disease in childhood, but has been seen 
even in early infancy. Its greater frequency in males holds good even in 
childhood. In a small number of cases heredity seems of some importance 
as an etiological factor. Leucaemia may follow syphilis, rickets, malaria, 
or even simple anaemia, or it may occur as a primary disease in children 
previously healthy. In the great majority of cases the cause is unknown. 

Lesions. — The essential lesions of leucaemia are found in the spleen, 
the lymphatic glands, and the bone-marrow. In rare cases the most im- 
portant changes are in the lymphatic glands, giving rise to the lymphatic 
form of leucaemia. In such cases the changes in the spleen or marrow 
may be slight or absent. Changes in the spleen and marrow are, however, 
usually associated, giving rise to what is known as the spleno-myelogen- 
ous form of the disease, which is the most frequent variety. The spleen 
is usually enormously enlarged, sometimes filling half the abdominal 
cavity. In the early stage it is soft, vascular, and of a dark-red colour ; 
in the late stages it is firm and hard, and usually deeply fissured at its 
margin. There may be perisplenitis. On section, light-gray patches of 
lymphoid tissue may be seen scattered throughout the organ, and in some 
instances there may be wedge-shaped infarctions. The microscope shows 
thickening of the trabecular and deposits of lymphoid tissue, especially 
about the arteries. The bone-marrow is of a yellowish-green or dark- 
brown colour, and shows immense numbers of nuclear red corpuscles in 
all stages of development, and many cells corresponding to the myelocytes 
found in the blood. The lymphatic glands, when they are involved, are 
not so uniformly enlarged as is the spleen. Any of the external glands 
of the body may be affected, the cervical, axillary, and the inguinal, or 
the mesenteric, tracheo-broncbial, the tonsils, and even the lymph nodules 
of the small and large intestines. The changes in the glands are gen- 



LEUCAEMIA. 807 

erally those of a simple hyperplasia. The liver is enlarged in very many 
of the cases, chiefly from an infiltration with lymphoid tissue, which may 
be diffuse or may occur in patches. Less frequently similar lymphoid 
masses are seen in other organs. 

Symptoms. — The blood (Plate XVI, A). — In gross appearance the 
blood is paler than normal, and the clot of a yellowish-green colour. The 
fibrin is usually increased. Both the specific gravity and the haemoglobin 
are diminished, the latter often being reduced to 25 per cent. The most 
important change is in the leucocytes. These are enormously increased, 
the proportion often being one to five of the red, and sometimes even one 
to two. 

In the spleno-myelogenous variety the predominant form is the large 
mononuclear cells with neutrophile granules, and are known as myelocytes 
(A, 2). The presence of the neutrophile granules distinguishes them from 
other mononuclear cells. The source of these is the bone-marrow, and 
they are not found in the lymphatic variety of the disease. In addition 
there is often an increase in the eosinophile cells (A, 1). The lympho- 
cytes are relatively diminished ; the percentage of the polynuclear neutro- 
phile cells (A, 3) is normal or diminished. The red corpuscles are mod- 
erately reduced in number, usually to from 30 to 50 per cent, and exhibit 
the irregularities in form and shape seen in other varieties of anaemia. 
There are also nuclear red-corpuscles present whose nuclei are some- 
times undergoing division. 

In the lymphatic form of the disease, the blood shows quite marked 
differences. The increase in the leucocytes is not so great, and is due 
solely to the increase in the number of lymphocytes, the myelocytes 
being absent. Occasionally both forms of the disease may be com- 
bined. 

The other symptoms of leucaemia in children resemble those in adults, 
with the difference that, as a rule, the progress of the disease is much more 
rapid in early life. In most of the cases the early symptoms are latent. 
A sudden and alarming haemorrhage is sometimes the first thing to call 
attention to the serious condition. In other cases there are only the 
symptoms of general weakness and anaemia. Sometimes the splenic 
tumour or the enlargement of the lymphatic glands is first noticed. In 
the early part of the disease, the usual symptoms of anaemia arc pres- 
ent,— digestive disturbances, shortness of breath, weak and rapid pulse. 
Haemorrhages may occur as an early or late symptom; they are mosl 
frequently from the nose, but severe haemorrhages may occur from the 
stomach, the mouth, the intestines, or there may he ecchymoses upon the 
skin. The enlargement of the spleen may he sufficiently marked to form 
an abdominal tumour, so as to attract the attention even of the parents. 
The swelling of the liver is not so great. The Lymphatic glands are 
enlarged only to a moderate degree, and in many cases this symptom is 



808 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

absent altogether. They are painless, movable, and usually several groups 
are affected. 

The late symptoms are dropsy of the feet or general anasarca, haemor- 
rhages, diarrhoea, headaches, general weakness, and attacks of fainting. 
Fever is quite constant in the late stages of the disease, and the tem- 
perature may be from 101° to 103° F. The urine may contain albumin 
and casts. Vision is sometimes disturbed by the formation of leucaemic 
plaques in the retina. It is rare that there are any symptoms referable 
to the bones, although expansion and tenderness of the flat bones have 
been observed. 

Course and Prognosis. — The course of leucaemia is chronic, and in 
most cases slowly progressive, but not always so. The prognosis is very 
bad, the great proportion of the cases in children proving fatal within a 
year from the first symptoms, in infancy sometimes in two or three 
months. There has been described by Epstein and others an acute form 
of the disease, proving fatal in a few weeks. The usual causes of death 
are exhaustion, haemorrhages, and broncho-pneumonia. 

Diagnosis. — This, in children, has to be made chiefly from simple 
anaemia with leucocytosis, and pseudo-leucaemic anaemia. Without a blood 
examination this is impossible. Reliance is to be placed upon the enor- 
mous increase in the leucocytes, and especially upon the presence of mye- 
locytes. In the other diseases mentioned there is simply an increase in 
the usual varieties of leucocytes ; different forms may predominate in 
different cases, but no new ones are present. 

Treatment. — The general treatment of leucaemia should be the same 
as that of anaemia. Of the drugs now in use, arsenic has altogether the 
most testimony in its favour. It must be given in large doses and for a 
long period. Next to this in value come iron and cod-liver oil. Leu- 
caemia, however, is in most instances very little influenced by treatment. 
The reported cures must be taken with some allowance, for most of these 
were published before the time when leucaemia was sharply differentiated 
from simple anaemia with leucocytosis and from the pseudo-leucaemic 
anaemia of infancy. 

HEMOPHILIA. 

Haemophilia is an hereditary disease, in which there is a tendency to 
profuse or even uncontrollable bleeding from slight wounds, or some- 
times arising spontaneously. In many cases there is associated an in- 
flammation of the joints. Persons so affected are known as " bleeders." 

Etiology. — The hereditary tendency of the disease is very strongly 
marked, and it has often been traced through seven or eight generations. 
Males are much more frequently affected than females, the proportion being 
about twelve to one. In the matter of inheritance, the disease is most 
often transmitted through the mother, who may, however, herself escape. 



PURPURA. 809 

Patients suffering from haemophilia have nothing else about them that is 
abnormal. The exact nature of the disease is unknown. It has no con- 
nection with either purpura or scurvy. Although generally classed 
among the diseases of the blood, it has not been established that there are 
any constant changes either in the blood or in the blood-vessels. 

Symptoms. — The first manifestations of haemophilia are not often seen 
before the second year. The haemorrhages of the newly-born have no 
relation to this condition. The discovery of the disease is generally quite 
accidental. The first haemorrhage may be traumatic or spontaneous. In 
traumatic haemorrhages there may be very severe bleeding after so slight 
a wound as the drawing of a tooth ; sometimes a large haematoma forms 
between the muscles as the result of a moderate contusion. 

The following is the relative frequency of spontaneous haemorrhages 
in 334 cases collected by Grandidier : bleeding from the nose in 169, 
mouth in 43, intestines in 36, stomach in 15, urethra in 16, lungs in 17. 
There may be haemorrhage from the skin or from any mucous membrane 
of the body. The attacks of spontaneous haemorrhage are often periodical, 
and may be accompanied by arthritic symptoms resembling rheumatism. 
The severity of the haemorrhages varies much in the different cases. 
From a slight wound a patient may bleed until he is exsanguinated, 
and even until death occurs. Such a result from the first haemorrhage, 
however, is rare. In some cases the disposition to bleed is outgrown in 
later life. Grandidier states that, of 152 boys, over one half died before 
reaching the seventh year. It is striking that when the disease affects 
females there is no tendency to excessive bleeding at menstruation or 
parturition. 

Treatment. — The indications at the time of bleeding are, to arrest the 
haemorrhage by the use of the ordinary surgical means — compression, 
styptics, etc.— and the nares should be plugged for severe epistaxis. Lit- 
tle benefit is to be expected from drugs. In convalescence after attacks 
of haemorrhage, iron and general tonics should be given. In all patients 
who are bleeders everything which might by any means excite hemor- 
rhage should be avoided. Marriage should be discouraged in girls who 
inherit the disease. 

PURPURA. 
The term purpura is used to designate a condition in which there is ;i 
tendency to spontaneous haemorrhages beneath the skin, from the various 
mucous membranes, and in some cases int.. the internal organs. The 
term purpura simplex is applied to those eases in which the haemor- 
rhages are limited to the skin; purpura hemorrhagica to those in which 
there is in addition bleeding from the mucous membranes or visceral 
haemorrhages. It is impossible to draw a line Bharply between these two 
classes of cases, as the chief difference between them seems to be one of 



810 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

degree. Purpura is sometimes known as morbus maculosus or as Werlhof's 
disease. 

Symptomatic Purpura. — This occurs in quite a variety of conditions, 
the haemorrhages generally being limited to the skin, but not always so. 
These cases may be grouped in the following classes : 

1. Infectious. — This form of purpura is very constantly seen jn ma- 
lignant endocarditis, in the hemorrhagic forms of the various eruptive 
fevers — measles, scarlet fever, variola, vaccinia, and typhus — also in epi- 
demic meningitis and occasionally in diphtheria, pyemia, and septicae- 
mia. The occurrence of haemorrhages in these cases appears to depend 
upon an altered condition of the blood, which is a direct result of the in- 
fection. In most of the diseases mentioned it is a bad prognostic sign, 
as it indicates a severe form of the disease, but it requires no special 
treatment. 

2. Cachectic. — Purpura occurs late in the course of many protracted 
and exhausting diseases, especially in infancy. It is most frequently met 
with in broncho-pneumonia, empyema, tuberculosis, ileo-colitis — in both 
the tuberculous and the simple forms of meningitis, and in malignant 
disease. It also occurs from apparently similar causes in several of the 
diseases of the blood, particularly in leucaemia and pernicious anaemia, 
and occasionally it is seen in chronic nephritis and in cardiac disease. In 
most cases of cachectic purpura the haemorrhagic spots are not very 
abundant, and occur either upon the abdomen or the lower extremities. 
They are usually small, but when once they have appeared new spots 
usually continue to come until death. This form is quite common in 
hospital practice, and when occurring in the course of the diseases men- 
tioned it is almost invariably indicative of a fatal result. Cachectic pur- 
pura is usually limited to the skin, haemorrhages from the mucous 
membranes being infrequent and visceral haemorrhages very rare. The 
condition is undoubtedly dependent upon a deterioration in the blood 
possibly also upon the condition of the minute blood-vessels themselves. 
Purpura adds nothing to the severity of the original disease, but is an 
indication of how extensive the blood changes are. It requires no special 
treatment. 

3. Toxic. — Certain drugs, such as phosphorus, quinine, potassium 
chlorate and sometimes others, may produce haemorrhages when long 
continued or in large doses. The haemorrhage of jaundice may also be 
considered in this group. All these conditions are extremely rare in 
childhood. 

4. Mechanical haemorrhages, such as those occurring in pertussis or 
epilepsy, are sometimes classed with purpura. In convalescence from pro- 
tracted illness there are sometimes seen, when patients first stand or walk, 
purpuric spots on the lower extremities. I have seen it after diphtheria. 
It may occur after prolonged confinement of a limb in bandages or splints. 



PURPURA. 811 

In both these cases the cause is partly mechanical and partly due to the 
weakened condition of the blood-vessels. 

5. Neurotic. — These cases are occasionally seen in diseases of the spinal 
cord and sometimes in hysteria in young adults, but very rarely in children. 

Primary Purpura. — This occurs in children of all ages, being not un- 
common in infancy. Haemorrhages of the newly-born have not generally 
been included in this class, although there are some reasons why they 
might well be. The age at which primary purpura is most frequently 
seen is from two to ten years. The sexes are about equally affected ; 
of Steffen's 56 cases, 27 were males and 29 females. The disease may 
occur in children who are cachectic, rachitic, or anaemic, and in those whose 
surroundings are poor, but it has not, like scurvy, any close relation to 
diet. It may follow any acute disease, being associated most frequently 
with derangements of the stomach and bowels. Quite frequently the 
disease develops abruptly, without any assignable cause, in children pre- 
viously healthy. It is not contagious. Epidemics of purpura have been 
reported, but these are somewhat doubtful, as they were recorded before 
this disease was sharply differentiated from scurvy. The association of 
purpura with rheumatism will be considered later. 

Lesions. — The external haemorrhages may occur upon any part of the 
body. There are smaller or larger ecchymoses or an infiltration of the 
tissues with blood, which undergoes gradual absorption with the usual 
changes. With the haemorrhages, various forms of inflammation of the 
skin may be associated, especially erythema and urticaria, with some- 
times more or less oedema. Free bleeding from the skin is very rare. 
Haemorrhages from the mucous membranes are more frequent, because of 
the feebler resistance of the tissues. There are seen ecchymoses upon the 
visible mucous membranes which resemble those upon the skin. At 
autopsy they are occasionally seen in the trachea or bronchi, but more 
often in the digestive tract. The stomach and intestines may contain 
dark, clotted blood, bloody mucus, or even fluid blood. In the colon, and 
occasionally in the small intestine, ulcers may be found; but they are 
rarely if ever seen in the stomach. They may be superficial or deep, and 
have even been known to cause perforation. The deep ulcers have gen- 
erally been attributed to thrombosis. Ulcers are often absent where in- 
testinal haemorrhage has been severe. Associated with these lesions there 
maybe inflammatory changes in the mucous membrane of the Btomach 
and intestines. 

Intracranial haemorrhages are rare, and those which occur are usually 
meningeal. These may be extensive and sufficienl to cause Bevere symp- 
toms. In 1803 a case occurred in the New Ymk Infant Asylum in an 
infant six months old, with an extensive meningeal hemorrhage covering 
a large part of the brain. In Steffen's paper several such cases are men- 
tioned. 



812 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

Pulmonary haemorrhages are not frequent. They generally occur as 
small ecchymoses just beneath the pleura. In one of my own cases, a 
hemorrhagic area as large as a walnut was found in the lung at one 
apex. Ecchymoses are found beneath the pericardium ; but endocarditis 
and pericarditis are extremely rare, probably occurring only in the rheu- 
matic cases. Fatty degeneration, with some degree of dilatation of the 
heart, has been seen in some of the most protracted severe cases. The 
spleen is occasionally enlarged, but by no means uniformly so, and it 
may be the seat of haemorrhages. The liver is normal, or the hepatic cells 
may be the seat of fatty degeneration. 

While haematuria is one of the most frequent of the visceral haemor- 
rhages, severe nephritis is rare. Acute degeneration of the renal epithe- 
lium of the tubes is quite common. There may be punctiform haemor- 
rhages, and occasionally larger ones beneath the renal capsule. Ecchy- 
moses may be found on the mucous membrane of the pelvis of the kidney. 
The suprarenal capsules may be the seat of extensive and even fatal 
haemorrhage, as in Wolff's case in a child two and a half years old. In 
addition to these lesions, there may be effusions of a sero-sanguineous fluid 
into any of the large serous cavities, most frequently into the peritonaeum. 
The articular lesions of purpura may be of a rheumatic character, with 
which purpura occurs as a complication ; or there may be haemorrhages 
into the tissues about the joint, or even into the joint itself, — usually the 
knee or elbow. 

Thus far no constant or essential changes have been demonstrated in 
the blood, other than those which are due to haemorrhages — viz., a mod- 
erate reduction in the haemoglobin and the red corpuscles, with occasional 
irregularities in size and the appearance of erythroblasts. In the most 
severe cases there is a moderate degree of leucocytosis. 

Pathology. — Why it is that under certain circumstances the blood- 
vessels will not hold their contents, it is difficult to understand. There 
have been described by Cassel, Riehl, Wilson, and others, changes in the 
small blood-vessels, usually a form of endarteritis. These changes are in 
all probability dependent upon some alteration in the blood itself. It 
is not necessary to assume a lesion in the blood-vessels, since we know 
that diseased blood may pass through even normal vessels. Henoch has 
suggested the vaso-motor origin of purpura, in which there is first a 
paralytic distention of the small vessels, followed by stasis, haemorrhage, 
or oedema. In certain forms, as in malignant endocarditis, it is well 
established that the cause is an infectious thrombosis. Although the bac- 
teriological examinations made thus far in purpura are not numerous 
enough to settle the question positively, there is little doubt that infec- 
tion is the essential factor in other forms of the disease, particularly in 
the cases characterized by sudden onset, high temperature, and cerebral 
symptoms, and which run a rapidly fatal course. This may possibly be 



PURPURA. 813 

true of most of the primary cases. At the present time the exact pathol- 
ogy of purpura is unknown. There are, no doubt, now included under 
this term, several diseases quite distinct from one another. 

The clinical types. — 1. The ordinary form. — In the mild cases the 
haemorrhage is confined to the skin (purpura simplex), or it is accom- 
panied by slight bleeding from the mucous membranes. There is usually 
some general indisposition of an indefinite character for a day or two be- 
fore the purpuric spots are noticed ; most frequently a disturbance of 
digestion with vomiting, diarrhoea, and sometimes slight fever. The 
haemorrhages appear as small petechias, varying in size from a pin's head 
to a pea; usually first upon the lower extremities, but sometimes first upon 
the trunk, the face, or the upper extremities. There may be only a few 
widely scattered spots or the body may be covered. The colour is first a 
bright red, then purple, gradually fading in the course of a few days. 
New spots come as the old ones disappear, so that the amount of eruption 
may not diminish ; often the spots come out in distinct crops. They do 
not disappear upon pressure. 

The course of these cases is generally favourable, recovery taking place 
in from one to four weeks under the influence of general tonic treatment. 
Relapses are, however, very frequent, and such attacks may come at inter- 
vals of a few weeks or months for a considerable period. One must be 
guarded in giving an absolutely favourable prognosis even in cases of such 
severity, for it occasionally happens that in a patient, who for several days 
has had symptoms of mild purpura, there suddenly develop those of the 
most severe type with a rapidly fatal termination. 

2. The severe form. — Such cases are characterized by haemorrhages 
from the mucous membranes (purpura haemorrhagica) from the outset. 
These may- even appear before the spots upon the skin. The relative in- 
tensity of the two varies much in different cases. In severe attacks the 
petechial spots are more likely to appear suddenly, and large ecchymoses, 
varying in size from a pea to the palm of the hand, are more frequent. 
There may be bleeding from the nose, gums, mouth, or pharynx, and 
ecchymoses maybe seen upon these mucous membranes, also upon the con- 
junctivae. Vomiting of blood and bloody discharges from the bowels are 
quite frequent symptoms. The urine may contain enough blood to give 
it a bright-red colour. Less frequently there are seen haemorrhages of the 
retina or choroid and from the female genitals. In one of mv own cases 
there was almost continuous bleeding from one car. HaBmoptysia and free 
bleeding from the skin are both rare. Cutaneous ecchj moses arc increased 
by slight injuries, such as the pressure from a bandage or from scratching. 
Epistaxis may be copious enough to necessitate plugging of the Dares. 
The amount of blood vomited is not often large; ita Bource may he the 
stomach, the mouth or the pharynx. The blood in the Btools is usually 
dark coloured, but there may be some bright-red blood even when there 



814 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

are no ulcers present. In one of my cases so much blood was lost by 
the bowels as to produce the symptoms of a very marked cerebral 
anaemia. In certain cases the gastro-intestinal symptoms are very promi- 
nent, and there may be slight icterus. The discharge of blood from the 
stomach or intestine may be accompanied by very severe attacks of colic 
and tenesmus. In some of these cases there are pains and slight swell- 
ing of the joints. Eenal symptoms are generally present. These attacks 
of pain with purpura and the discharge of blood, may come on paroxys- 
mally every few days for a period of several weeks. They have been 
ascribed to thrombosis of the intestinal vessels. This is sometimes known 
as " Henoch's purpura." 

Constitutional symptoms are present in most of the severe cases. 
There is usually fever, from 101° to 103° F., and sufficient prostration to 
keep the patient in bed. If the amount of blood lost is large, there are 
the usual symptoms of severe anaemia, — pallor, weak pulse, cold extremi- 
ties, fainting attacks, and functional heart murmurs. The loss of blood 
may be sufficient to cause death, particularly in infants. Cerebral symp- 
toms may depend upon anaemia or upon meningeal haemorrhage. They 
are not frequent in this form of the disease. (Edema, especially of the face 
and feet, may exist without albuminuria, and albuminuria may be present 
in cases in which there is no renal haemorrhage. The amount of albumin 
is generally small, and casts are rare. 

In some of the cases beginning with severe general symptoms, and 
occasionally when the onset is mild, the patients after a few days pass into 
a typhoid condition with low delirium, great prostration, weak and irregu- 
lar pulse, dry, cracked tongue, and high temperature. Such cases are 
almost always fatal. They are not to be confounded with ordinary typhoid 
fever complicated by purpura. 

The course varies much in the different cases. It lasts from one to 
six weeks, the symptoms slowly subsiding, but often showing a strong 
tendency to recurrence. The prognosis depends upon the age of the 
patient, the extent of the haemorrhage, and the presence or absence of 
septic symptoms. 

3. The hyper-acute form (purpura fulminans). — This is a rare form, 
especially in young children. Its development is usually sudden with a 
chill, vomiting, marked prostration, and high temperature. The purpuric 
spots come out with great rapidity, and in the course of a few hours or a 
day they may be very extensive. In addition to the ordinary subcutane- 
ous haemorrhages, bloody vesicles may form upon the skin. In many cases 
the haemorrhages are limited to the skin, the mucous membrane and the 
viscera escaping altogether. There is no tendency to gangrene. Cerebral 
symptoms are invariably present and usually prominent ; there may be 
delirium, dulness, stupor, and finally coma. The spleen is apt to be en- 
larged. The urine is nearly always albuminous. This form of purpura 



PURPURA. 815 

has all the characteristics of a general infectious disease, and it is almost 
invariably fatal. But little is as yet definitely known regarding its cause 
or its relation to the other forms. 

4. The gangrenous form. — Sloughing is not common in purpura, but 
it is most, often seen in the mucous membranes. Osier refers to two 
cases affecting the uvula. 1 once saw a slough which caused perforation 
of the soft palate. Wickham Legg reports a case with gangrene of the 
prepuce. The deep ulcers of the intestine which are seen in some of the 
severe cases are apparently necrotic rather than inflammatory. Gan- 
grene of the skin is even less frequent, although cases have been reported 
even in young children. Charron's case was only three years old, and 
several others in children are collected in Gimard's monograph upon this 
subject. The gangrene may involve the skin only, or the subcutaneous 
tissues and even the muscles. It has been seen upon the upper and lower 
extremities and even upon the face, and may extend over quite a large 
surface. In some of the milder forms of purpura, gangrene results from 
some slight injury, such as a blow, the pressure from a bandage, or in the 
nose, from the pressure of a tampon. In the gangrenous cases, all the 
symptoms are usually severe and indicate extensive blood alteration. 
They are almost invariably fatal. Those in which the sloughing is con- 
fined to small areas of the mucous membrane of the mouth often recover. 

5. The rheumatic form. — Rheumatic purpura (peliosis rheumatica) is 
applied to cases, not so common in children as in older patients, in which 
subcutaneous haemorrhages, and sometimes bleeding from the mucous 
membranes, are associated with painful joint swellings. These are to be 
regarded as cases of rheumatism complicated by purpura. The joints 
most frequently affected are the knee and the ankle. The arthritic symp- 
toms are usually less severe than in attacks of acute rheumatism. There 
may be present erythema exudativa or erythema nodosum or urticaria. 
Usually there are throat symptoms and fever, and frequently oedema of 
the face and eyelids with albuminuria. The spleen maybe enlarged. The 
usual duration is from one to three weeks, and although relapses may 
occur, the cases usually recover. 

Joint symptoms, particularly articular pains, are not infrequenl in the 
course of milder attacks of purpura without the febrile symptoms men- 
tioned. In severe cases extravasations of blood have been reported as 
occurring in the tissues about the joints, and even in the joints themselves, 
these being cases of true arthritic purpura. It is probable that, in the 
past, some cases of scurvy have been included in this category. 

Diagnosis. — The rapid acute cases may be confounded with the hem- 
orrhagic forms of the various eruptive fevers. The ordinary subacute or 
passive forms are chiefly to be differentiated from scurvy. The diagnosis 
is not difficult and the mistake need not be made if the essential features 
of scurvy are borne in mind, — its dietetic cause, bleeding gums, hyperses- 



816 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

thesia, and deep rather than subcutaneous haemorrhages which are usu- 
ally near the joints. 

Prognosis. — This depends very much upon the form of the disease. 
Of 128 cases of all varieties occurring in children in Steifen's collection, 
there were 40 deaths. In 12 cases of severe primary purpura reported by 
Gimard, there were 3 deaths and 9 recoveries. Purpura simplex is rarely 
fatal ; cases of purpura hemorrhagica usually recover unless marked feb- 
rile symptoms are present. The forms classed as typhoid, gangrenous, 
and purpura fulminans are almost invariably fatal. The tendency to 
relapses exists in all varieties. 

Treatment. — The treatment of symptomatic purpura should have ref- 
erence to the cause of the disease. The mild cases of primary purpura 
usually recover promptly under a tonic plan of treatment. The more severe 
cases require confinement in bed, absolute quiet, and care to avoid expos- 
ure and even the slightest injury or extra pressure upon any part. Drugs 
do not seem to influence the course of the disease in any constant and 
uniform way. Those most frequently employed are hydrastis, hama- 
melis, aromatic sulphuric acid, the vegetable acids, ergot, and gallic 
acid. Iron should be deferred until active haemorrhage has ceased. 
Whether or not it is true, as claimed by some, that all haemorrbagic dis- 
eases are related to scurvy, the striking improvement seen in this disease 
from the use of fresh fruit and vegetables, suggests their employment in 
purpura. In some cases very decided benefit seems to follow their use in 
the acute stage, but more particularly in convalescence. For hyperacute 
and gangrenous cases, little can be done except to treat the symptoms. 
Surgical means of arresting the haemorrhage are rarely successful. Iron 
and arsenic and alcoholic stimulants should be used in all cases during 
convalescence. 



CHAPTER II. 
DISEASES OF THE LXMPH NODES {LYMPHATIC GLANDS). 

LYMPHATISM. 

It is characteristic of infancy and childhood that the lymphatic glands, 
or the lymph nodes, as they are now coming to be generally called, through- 
out the body are prone to swelling and hyperplasia. While this tendency 
belongs to all children, in certain individuals it is so marked as to deserve 
a place as a distinct diathesis. It was formerly classed as one of the mani- 
festations of ' ; scrofula " or " struma " ; but the proof that most of the 
manifestations formerly classed as " scrofulous " are really forms of local 
tuberculosis, makes it undesirable to use that term any longer as descrip- 



LYMPHATISM. 817 

tive of conditions now known to be often due to other causes besides 
inherited tuberculosis. The term lymphatism has been used by Potain 
and other French writers, and in this country by Bosworth, to designate 
this condition. 

In stout, robust children, infectious processes of the nose, pharynx, or 
bronchi, cause acute swelling of the lymph nodes in the neighbourhood, 
but these rapidly subside when the cause is removed. In others, in whom 
a certain constitutional condition exists, the process in the mucous mem- 
brane is likely to be protracted, and the enlargement of the lymphatic 
glands once started continues even after the primary cause has subsided ; 
or, diminishing for a time, it increases again with every new exciting 
cause until permanent enlargement may be produced. 

I shall use the term lymphatism in the sense indicated, — viz., to desig- 
nate an exaggerated susceptibility of the lymphoid tissue, a constitutional 
condition in which any inflammation of the mucous membranes or skin 
sets up hyperplasia in the lymph nodes with which these parts are con- 
nected, which is out of proportion to the exciting cause and which tends 
to continue after it has ceased to operate. Besides, there must be included 
in this category, children who at birth have an excessive development of 
lymphoid tissue, seen particularly in the region of the throat in the form 
of enlarged tonsils, adenoid vegetations of the pharynx, etc. 

Lymphatism may be inherited or acquired. The influence of heredity 
is too often seen to be passed over as a coincidence. Frequently the 
parents, when children, suffered from the same condition, and very often 
every member of a large family of children is affected. This may be the 
case in those who are in other respects healthy, who have been reared amid 
good surroundings, and in whom no evidence of any other constitutional 
disease can be found. Any disease in the parents in consequence of which 
children are born with tissues having less than normal resistance, may be 
regarded in the light of a remote cause. As such may be mentioned gout, 
rheumatism, alcoholism, syphilis, or tuberculosis, the child under these 
conditions inheriting not the disease, but, so to speak, its consequent 

Among the causes operating after birth to produce lymphatism, the 
surroundings of the child are of the first importance. It is seen to per- 
fection in children reared in institutions; it is also frequent in crowded 
tenements and in cities rather than in the country. Anything which 
produces malnutrition or lowers the general vitality of the tiasuea may be 
ranked as a cause. Rickets and lymphatism are very frequently associated ; 
sometimes rickets is to be reckoned as a cause, and sometimes both con- 
ditions depend upon the same causes. 

The local manifestations of lymphatism -uv modified by the age of the 
child. During infancy, the glands which arc most frequently affected are 
those connected with tl le gastro-enteric and the bronchial mucous mem- 
branes; in childhood it is those which are connected with the pharyni 

61 



818 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

and tonsils. This localization, of course, depends largely upon the fact 
that the susceptibility of the differeut mucous membranes is greatly influ- 
enced by age. 

The degree of enlargement of the lymph nodes which is sometimes 
found in the different situations has often led to a misinterpretation of 
them, particularly by those who only seldom see autopsies upon infants 
or young children. They have often been connected with pathological 
conditions or clinical symptoms with which they have really nothing to 
do. One or two examples will suffice : 

Enlargement of the mesenteric glands and of the solitary follicles of 
the large and small intestine, are very frequently seen in infants who have 
died of marasmus, and have been regarded as the cause of the wasting, 
while in reality they were only the consequence of the chronic indigestion 
which is an almost constant accompaniment of that condition. The find- 
ing of swollen Peyer's patches in cases of acute diarrhoea, with some 
other symptoms during life suggestive of typhoid fever, have often been 
looked upon as a confirmation of that diagnosis, as in a recent case 
reported by Northrup, in which cultures showed that the disease was not 
typhoid. 

The condition under consideration relates not only to the larger lymph 
nodes, but to the smaller ones discernible only by the microscope. Where 
the larger ones exist, immense numbers of the small ones are sure to be 
present. 

Lymphatism is essentially a condition of childhood. As time passes 
we see a regular succession of retrograde changes in the different series 
of glands unless they become the seat of tubercular infection. Those con- 
nected with the digestive tract begin to diminish after the second year, and 
by the fifth or sixth year the enlargement has almost disappeared ; while 
the tonsils, adenoid growths of the pharynx, and enlarged cervical glands 
are usually stationary after the seventh or eighth year and undergo quite 
a marked atrophy about the time of puberty. The presence of these en- 
larged lymph nodes, the catarrhal condition of the mucous membranes 
with which they are associated, and the constitutional condition upon 
which both depend, are important in relation to all acute infectious dis- 
eases which affect these mucous membranes. They bring about an in- 
creased susceptibility to scarlet fever, measles, diphtheria, diarrhoeal dis- 
eases, and most of all to tuberculosis. 



SIMPLE ACUTE ADENITIS. 



819 



Table showing the Situation and the Drainage- Areas of the Various 
Groups of Lymph Nodes of the Head and Neck* 



Name of the 
group. 



1 j Sub-occipital 
Mastoid. 



Parotid. 



Submaxil- 
lary. 



9 
10 



Supra-hyoid. 

Superficial 
cervical. 



Deep cervi- 
cal, upper 
set. 



Deep cervi- 
cal, lower 
set. 

Sub-hvoid. 



Retro-phar- 
yngeal. 



Number and situation. 



One or two ; at nape of neck. 
Four or five small ones ; in 

mastoid region. 
Five to ten ; on the surface 

and in the substance of 

the parotid gland. 

Twelve to fifteen : along base 
of jaw, beneath cervical 
fascia. 

One or two ; median line be- 
tween chin and hyoid bone. 

Five or more ; along external 
jugular vein, beneath pla- 
tysma, but superficial to 
the sterno- mastoid. 

Ten to sixteen ; about bifur- 
cation of common carotid 
and along internal jugular 
vein. They are just above 
upper border of thyroid 
cartilage and on a level 
with hyoid bone. 

A chain in the supra-clavicu- 
lar fossa. 



A few small glands below 
hyoid bone and near me- 
dian line. 

Two small glands in front of 
spine and upon preverte- 
bral muscles. 



Organs or areas from which they receive 
lymphatics. 



Scalp, posterior portion. 

Receive efferent vessels from group 1, 

and through them from part of scalp. 
Scalp, frontal and parietal portions ; 

orbit, posterior part of nasal fossa, 

upper jaw, posterior and upper part 

of pharynx. 
Mouth, lower lip, gums. 



Chin and middle portion of lower lip. 

Auricle, part of scalp, skin of face 
and neck, and some efferent ves- 
sels from groups 1 and 2. 

Lower part of pharynx, larynx, palate, 
tonsils and part of tongue, part of 
nasal fossa, deep muscles of head 
and neck, and from inside the crani- 
um. Receive also efferent vessels 
from groups 3 and 4. 

Connect with axillary group by a chain 
along axillary artery; also with 
glands of mediastinum and with 
groups 7 and 9. 

Communicate with group 8, and may 
connect below with chain of bron- 
chial glands. 

Pharynx and part of nasal fossa. 



SIMPLE ACUTE ADENITIS. 

This is an acute inflammation of the lymph nodes which in infancy 
frequently terminates in suppuration. A certain amount of inflamma- 
tion of the Ivmph nodes occurs in children in all acute processes affect- 
ing the mucous membranes, especially when fchey arc severe or prolonged. 
Those in connection with the various internal organs ate considered with 
the diseases of the organs. Acute inflammation of the external nodes 
is of sufficient frequency to require separate consideration. While this 
is probably always secondary to some pathological process in the skin 
or mucous membranes, the primary condition may be SO slight ;i< to be 
overlooked, and the adenitis may be the more important condition or may 
even assume the appearance of a primary disease. It is particularly in 



* Modified from Treves after Curnow in the Lancet, 1ST!), vol. i, p. ::'.'7. 



820 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

infants that this is seen, and it depends upon the unusually active absorp- 
tion and upon the susceptibility of the lymphoid tissues at this age. The 
cervical glands are frequently affected, and occasionally those of the axil- 
lary and inguinal regions. 

Etiology. — Acute adenitis occurs in children of all ages in connection 
with diphtheria, scarlet fever, measles, and influenza. In such cases it is 
often severe, and, particularly with scarlet fever, not infrequently ends in 
suppuration. With the simple acute catarrhal processes of the pharynx 
and rhino-pharynx adenitis also occurs, but it is usually mild and rarely 
suppurates. In infancy, on the other hand, acute adenitis is not only very 
common from simple catarrh, but often severe, and frequently terminates 
in suppuration. Ulcerative stomatitis, carious teeth, eczema of the scalp 
or traumatism, may excite adenitis in children of all ages. Axillary 
adenitis may result from vaccination ; inguinal adenitis from vaginitis. 

Of 109 cases of acute adenitis, not including those associated with 
diphtheria, measles, or scarlet fever, more than three fourths occurred in 
the first two years, and half of them in the first year of life. This sus- 
ceptibility of infants is very striking. The disease occurs frequently in 
those who are in other respects perfectly healthy, and often when the 
evidences of disease of the mucous membrane are slight. This is true 
not only of the cases of cervical adenitis, but also of others in which the 
inguinal glands are involved. The inflammation is excited in most of 
these cases by the absorption of pyogenic germs from the mucous mem- 
branes or skin ; in some cases, as in diphtheria, probably by the action of 
toxines. 

Lesions. — The changes taking place in the glands are acute con- 
gestion, with swelling, oedema, and active hyperplasia of the lymphoid 
elements. The process may terminate in resolution or in suppuration 
according to the intensity of the infection and the susceptibility of the 
tissues. When severe enough to cause suppuration, the adenitis is accom- 
panied by considerable inflammation of the surrounding cellular tissue. 

In a series of 109 acute cases of which I have notes, not including the 
specific infectious diseases, 96 were cervical, 9 were inguinal, and 4 axil- 
lary ; 62 per cent terminated in suppuration, the latter being nearly all 
in infancy. Suppurative otitis was present in 16 per cent of the cases. 
Suppurative retro-pharyngeal adenitis (retro-pharyngeal abscess) was seen 
in several cases. 

In infancy the disease is usually unilateral, or, if bilateral, the glands 
of one side are much more severely affected than those of the other. Sup- 
puration is nearly always of one side, and usually the abscess starts from 
a single gland. 

Symptoms. — The symptoms and course of the adenitis of the specific 
infectious diseases belong to their clinical history. Suppuration is infre- 
quent, except after scarlet fever. It is very rare after diphtheria, and 



SIMPLE ACUTE ADENITIS. 



821 




when present usually signifies mixed infection ; I have seen it occur but 

twice. 

The typical cases of acute adenitis are those which occur in infancy. 

There are present the symptoms of the original disease, — usually catarrh 

of the nose or rhino-pharynx, mouth, 

or ear, which may not be very severe, 

and sometimes is overlooked. The 

glands most frequently affected are H 

the deep cervical group. The tumour 

appears just below the angle of the 

jaw at the anterior border of the 

sterno-mastoid muscle (Fig. 141). 

The swelling during the acute catarrh 

is not rapid or great, but continues 

after the original process has subsided 

until it reaches the size of a walnut 

or even a pigeon's egg. In the most 

acute cases there is marked inflamma- 
tion of the periglandular cellular tis- 
sue, with pain, tenderness, and extra 

heat. If suppuration occurs, it is gen- 
erally evident in the latter part of the 

second week, but sometimes it may 

be as late as the third or even the 

fourth week. In the axillary or inguinal region (Fig. 142) the symptoms 

of adenitis are essentially the same as in the neck. In the inguinal cases 

the degree of catarrh of the mucous membrane is often very slight. 

Most cases run their course with 
slight fever and few general symp- 
toms; but in young infants the con- 
stitutional symptoms are often Bevere 
and the physician may be in doubt 
whether the local process is suffi- 
cient to explain them. The temper- 
ature may be from 102° to 104° F. for 
several days, with considerable pros- 
tration, which is much increased if 
there is complicating otitis. After 
suppuration, if freely opened a1 the 
proper time, the abscess heals rapidly 
and permanently, a Binus being rare. 
Occasionally infection extends from 
one gland to another, and a succession 

Fig. 142.— Acute suppurative adenitis (in- . , . , , , __„_ nnn „ v . cy 

guinal) in an infant three months old. of these glandular ahscesses OCCUrS. 



Fig. 141. — Acute suppurative adenitis in an 
infant one year old, Bhowing the most fre- 
quent situation of the tumour in the cervi- 
cal region. 




822 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

In the non-suppurative cases the swelling may be even greater than in 
those which suppurate ; but it is less diffuse and apparently limited to the 
gland. It subsides slowly in the course of from four to eight weeks, often 
leaving a small tumour which may be apparent for several months. In 
susceptible children recurrent attacks of acute inflammation may lead to 
chronic enlargement which may last indefinitely. These glands do not 
become cheesy, except from subsequent tuberculous infection. 

The acute cases in infancy in which suppuration occurs, appear to 
recover about as promptly and quite as completely as those terminating 
in resolution, although in the former the constitutional symptoms are 
more severe. 

Diagnosis. — This is usually easy if it is remembered that, with the ex- 
ception of the specific infectious diseases, and occasionally local causes like 
eczema of the scalp, carious teeth, etc., acute adenitis is essentially a dis- 
ease of infancy. I have often seen it mistaken for mumps when the 
swelling was severe, but on close examination there is but little resem- 
blance between the conditions. The disease is essentially acute, and has 
nothing in common with the slow suppuration seen in later childhood 
from the breaking down of tuberculous glands. 

Treatment. — Prophylaxis requires that in all acute catarrhs, the mucous 
membrane should be kept as clean as possible by the use of nasal or 
pharyngeal sprays, or by syringing with simple solutions like Dobell's or 
Seller's (page 56), or one of common salt. 

In the stage of acute inflammation very hot applications or an ice-bag 
may be used for the relief of pain. It is very doubtful whether either of 
these means has much influence in preventing suppuration. If abscess 
forms, incision had best be deferred until pointing has taken place. If 
this plan is followed, refilling is rare. A simple free incision with proper 
antiseptic treatment is all that is required. Curetting may be done if 
there is much broken-down tissue present, but it is not usually necessary. 
In most of the cases the abscess promptly heals and a perfect cure takes 
place. In cases which do not suppurate, absorption may be promoted by 
the internal use of the iodide of potassium in full doses, — gr. x to xv daily 
to an infant of one year. I confess rarely to have seen any benefit from 
painting with iodine or from inunctions of iodine ointment or the oleate 
of mercury. If adenitis is secondary to carious teeth, eczema, or ulcerative 
stomatitis, these conditions should receive appropriate treatment. Such 
cases do not usually suppurate, but subside rapidly when the primary 
cause is removed. 



SIMPLE CHRONIC ADENITIS. 

This consists in a simple hyperplasia of the lymph nodes. There are 
considered here only the external glands, but those of the cavities of the 



SYPHILITIC ADENITIS. 823 

body are affected in a similar way, in diseases of the mucous membranes 
with which they are connected. 

Simple chronic adenitis is not nearly so frequent as the acute form 
even in infants and young children, and it is rare after the fifth year. It 
may follow one or more attacks of acute adenitis, or it may result from 
subacute or chronic inflammations of the skin or of the various mucous 
membranes, infection from which causes the acute form. The same 
groups of glands are affected in both varieties. The most frequent sub- 
jects are children who have the diathesis described as lymphatism. 

Symptoms. — The glands upon both sides of the neck are usually 
involved, and more often a group than a single gland. The degree of 
swelling is not generally great, being much less than in acute adenitis, 
and usually less than in the tuberculous form. There are no constitutional 
symptoms. Hypertrophy of the tonsils and adenoid growths of the pharynx 
are frequently present. There is seen no tendency to suppuration or case- 
ation. The swelling usually increases slowly for one or two months, then 
remains stationary for about the same length of time, after which it slowly 
subsides, although it may not entirely disappear for years. A subacute 
course is more frequent than a very chronic one. 

Diagnosis. — These cases are especially to be distinguished from those 
of tuberculous adenitis. The most important points for differentiation 
are : that they occur, as a rule, in children under five, and most frequently 
under three years, a period when tuberculous disease is not very common ; 
that some definite exciting cause is usually present ; that caseation and 
suppuration do not occur ; that the glands do not become adherent to the 
skin or to the deeper tissues ; that they enlarge much more rapidly than 
do the non-caseating tuberculous glands ; and that they are influenced to 
a much greater degree by constitutional treatment. There are, however, 
some cases in which a differential diagnosis is impossible. Glands in 
which there was originally only a simple hyperplasia may undoubtedly 
become tuberculous by subsequent infection. 

Treatment. — Operative measures are not called for. The local cause 
usually to be found in the pharynx, nose, or mouth — hypertrophied tonsils, 
adenoid vegetation of the pharynx, decayed teeth, etc. — should be removed 
whenever possible. Little benefit is seen from local applications. The 
syrup of the iodide of iron (twenty drops throe times a day to a child of four 
years) or potassium iodide (five grains three times a day) should be given 
for a long period. In some cases more decided benefit is Been from arsenic 
(four drops of Fowler's solution in a glass of water three times ;i day). 
In all cases cod-liver oil should he given except daring warm weather. 

SYPHILITIC ADKNITIS. 

It is quite rare that a marked degree of glandular enlargement is seen 

as a symptom of hereditary syphilis; indeed, so rare that it i> often for- 



824 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

gotten that chronic multiple glandular enlargements are ever due to this 
disease. In the few examples that have come under my observation, this 
has been a late symptom of hereditary syphilis. The glandular enlarge- 
ments have been cervical and multiple, and the degree of swelling has 
often been marked. They may be associated with disease of the bones or 
mucous membrane of the throat or of the nose, or without signs of such 
disease. The diagnosis of syphilis rests upon the association of other 
late manifestations of the disease — keratitis, periostitis, deformities of the 
teeth — and the prompt improvement under anti-syphilitic treatment. In 
their local appearance they resemble tuberculous glands. 

TUBERCULOUS ADENITIS. 
Synonym : Scrofula. 

Tuberculous disease of the lymph glands of the cavities of the body 
is discussed elsewhere ; only that of the external glands is here consid- 
ered. These present some striking peculiarities, — they are relatively rare 
in infancy, although a frequent form of tuberculosis in older children ; it 
is exceptional to find them associated with general tuberculosis, and then 
they more often follow than precede the general disease. In the great 
majority of cases it is the cervical glands which are affected. 

Etiology. — The age at which tuberculosis of the cervical lymph glands 
is usually seen is from three to ten years. In my experience with tuber- 
culosis in infancy, the external glands are rarely involved, this being in 
striking contrast to the regularity, almost uniformity, with which the 
bronchial glands are the seat of infection. 

In addition to infection with the tubercle bacillus, local causes are 
usually present ; the most important are adenoid growths of the pharynx, 
chronic pharyngitis, and hypertrophied tonsils ; less frequently there are 
chronic otitis, chronic conjunctivitis, and pathological processes of the skin 
or the mouth, such as eczema of the face or scalp, ulcerative stomatitis, 
carious teeth, etc. For the production of the disease, therefore, there ap- 
pear to be necessary, first, favourable local conditions, and, secondly, ex- 
posure to infection. That the pharynx is the most frequent seat of primary 
infection, is shown by the fact that the deep cervical glands are generally 
first affected. The question often arises whether the process in the glands 
is at first simple, and later becomes tuberculous, or whether it is tubercu- 
lous from the outset. No doubt there are many examples of both condi- 
tions ; however, my own conviction is that in the majority of cases the 
process is a tuberculous one from the beginning. 

Children who are by inheritance predisposed to tuberculosis and those 
also who are prone to glandular enlargements — two conditions which are 
by no means identical — are the ones most liable to be affected. Attacks of 
acute infectious diseases, particularly measles, scarlet fever, and influenza,, 
frequently play the role of exciting causes. 



TUBERCULOUS ADENITIS. 825 

The age of those affected corresponds very closely with that at which 
most children are seen with hypertrophied tonsils and adenoid growths 
of the pharynx. The subsidence of symptoms about the time of puberty, 
is also characteristic of both conditions. 

Lesions. — It has been already stated that in the great majority of 
cases the cervical glands are involved, and generally they are the only 
ones affected. In 155 cases of tuberculous glands in the series re- 
ported by Treves,* those of the neck were the seat of disease in 145 and 
the only seat in 131 ; those of the axilla were involved in 17, but alone 
only in 4 ; the groin in 8, and alone in 6. This indicates the close asso- 
ciation of the disease with infection through the upper respiratory tract. 
The glands first affected are most frequently the upper set of the deep 
cervical group ; sometimes, however, it is the superficial glands of the sub- 
maxillary, or the parotid group, and occasionally the submental or the 
pre-auricular.f The chain of deep cervical glands which is involved, 
follows the carotid artery, and often extends some distance below the 
clavicle. These deep glands are sometimes connected with the bronchial 
group. 

The process in all tuberculous glands is essentially a chronic one, but 
pathologically the cases may be divided into two groups, corresponding 
somewhat to the forms of disease seen in the lungs. In the first group 
the process is more rapid, and tends to early caseation and softening ; the 
products of inflammation are mainly cellular, and the amount of fibrous 
tissue is small. In the second group the course is much slower, and fibrous 
tissue predominates, the cells being fewer, and caseation and softening 
infrequent. 

In the first group the glands in the early stage are swollen, of a pale 
pink colour, and homogeneous ; later they become more firm, and show, 
as the first gross evidence of tuberculous deposits, small grayish-white 
spots, which are generally numerous and scattered through the affected 
gland ; these spots enlarge, and may coalesce to form one large gray 
mass, involving nearly the whole gland. Subsequently there is caseation 
and then softening, usually beginning in the centre of the caseous area. 
Inflammation within the gland is followed by that of the surrounding 
tissues, which may result in adhesions or in the formation of a periglandu- 
lar abscess. The first change in the gland is the production of epithe- 
lioid and giant cells, about which there is a zone of small round cells; 
cheesy degeneration then begins in the centre The caseous masses may 
become encapsulated by the production about them of fibrous tissue; or 
softening may occur at one or more foei, and an abscess form. Such afl 
abscess contains curdy materials but very little true pus, the contents being 



* Scrofula and its Gland Diseases. Smith. Elder & Co., Loudon, 1883. 
f Niooll, Glasgow Medical Journal, January, i s '."'>. 



826 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

chiefly parts of the gland not completely broken down. Caseation may be 
followed by calcareous degeneration, although this is rare, much more so 
than in the mesenteric or bronchial glands. Tubercle bacilli are usually 
more numerous in the early stages of the process, but are often difficult of 
detection in late cases in broken-down tissues, and the curdy pus is some- 
times sterile. As the glands soften, the process gradually extends from 
the centre to the surface, and they become adherent to the surrounding 
structures — blood-vessels, nerves, organs, or the cellular tissue — they fuse 
together and form large knotty masses, and when they ultimately break 
down they lead to the formation of abscesses in the cellular tissue, finally 
involving the skin. In the form of suppuration which occurs in and 
about tuberculous glands, an important part is often played by other bac- 
teria, usually the staphylococcus or the streptococcus. 

In the second group of cases, where the process goes forward more 
slowly, the changes are not quite the same, the essential difference being 
that the amount of fibrous tissue is much greater. These glands are not 
so vascular ; they are tough and hard, appearing like small fibrous tumours. 
The capsules are greatly thickened, and under the microscope is seen 
fibrous tissue arranged in concentric layers, often inclosing small caseous 
masses. These glands less frequently form adhesions to the surrounding 
tissues, and consequently are freely movable, while suppuration is the rare 
exception. Although the separate tumours are much smaller than in the 
first group, the glandular mass is often a large one, because of the number 
of glands involved. 

Treves gives some interesting observations in regard to the spreading 
of the process from one gland to another. He states that while it often 
takes place along the direct line of the lymph current, this is not always 
the case, and sometimes it spreads in exactly the opposite direction. This 
he believes to be due to an extension of disease from the gland to the 
afferent lymphatics, these vessels themselves becoming the seat of disease, 
with changes similar to those taking place in the glands. In consequence 
of this many more tuberculous nodes may be found than there were 
originally lymph glands, — a point which has often been noticed, but for 
which there is no other satisfactory explanation. 

Symptoms. — In the early part of the disease there • are no symptoms 
but glandular swelling, and this begins very gradually, often insidiously. 
In the majority of the cases both sides are involved, although one fre- 
quently begins before the other and advances more rapidly. The enlarge- 
ment is not always continuous ; it may increase for a time and then remain 
stationary or even diminish, to take a fresh start under the stimulus of 
some new process in the mucous membrane with which the glands are 
associated, such as an attack of measles or scarlet fever, or simply from a 
depreciation of the patient's general health. During exacerbations, the 
glands may be painful and tender, and show the usual signs of local inflam- 



TUBERCULOUS ADENITIS. 827 

mation. The whole course of the disease varies from several months to as 
many years. Treves gives three and a half years as the average duration 
where suppuration occurs. The glands first affected are usually those 
situated near the bifurcation of the common carotid artery. Such tumours 
usually make their appearance just in front of the sterno-mastoid muscle — 
sometimes behind it — and at the level of the upper border of the larynx or 
the hyoid bone. In the more rapid cases the tumours usually attain a con- 
siderable size ill three or four months, sometimes in half that time. The 
usual size reached is from that of an almond to an English walnut. At 
first the tumours are movable and preserve their distinct outline ; later 
they become adherent, first to the deeper tissues and to each other, finally 
to the skin, and there is formed an irregular nodular mass in which it is 
sometimes difficult to make out the individual glands. As they approach 
the surface there are small spots of softening ; then there is distinct fluc- 
tuation ; the skin becomes discoloured and finally gives way, and there is 
a discharge of thick, curdy pus, which may continue for an indefinite time, 
until the whole of the broken-down gland has been thrown off. 

In the cases which progress more slowly, a chain of glands is usually 
involved which individually are smaller than the preceding, and yet to- 
gether they may form quite a large mass. These rarely become adherent, 
except to each other, and suppuration is very infrequent ; the skin over 
them therefore is generally healthy. In most of the cases where suppura- 
tion has not occurred an improvement takes place about the time of 
puberty. In what proportion of these glands there is suppuration it is 
impossible to say. Like other tuberculous lesions in the body, these glands 
are much more often the seat of infection than was formerly supposed, 
and in many cases the diagnosis is not made. Of those recognised clinic- 
ally as tuberculous adenitis, from one half to two thirds suppurate, pro- 
vided they are allowed to run their natural course. Resolution is more 
likely to occur where the progress is slow, and where there are many 
small tumours than with one or two large ones. If softening has oc- 
curred, resolution is not to be expected, although even in such cases 
encapsulation of the cheesy foci may take place. Occasionally cases art- 
cured by intercurrent acute disease. A cure has been known to follow an 
attack of scarlet fever, and erysipelas of the face (Treves). The usual 
effect of the eruptive fevers, however, is to accelerate the pro< 

Twoformsof suppuration occur in connection with tuberculous glands, 
one an abscess of the gland proper, the other outside of ami usually 
over it. In a typical case of the firsl variety, the gland is distinctly out- 
lined and often superficial, there is very little inflammation, the Bpol of 
softening and fluctuation is small, and the pus discharged is always curdy. 
In the second variety the abscess is preceded by a more diffuse swelling, 
and the outline of the gland may not be made out ; the Bigns <>f inflam 
mation are more marked, the area of fluctuation is larger, and the pus is 



828 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

more like that of any ordinary abscess. Often the two varieties are com- 
bined ; as when a gland beneath the deep fascia breaks down and there is 
formed directly over it an abscess in the cellular tissue, which communi- 
cates through a narrow opening with the gland beneath. In such cases 
the discharge may continue for a very long time, until the whole of the 
gland has been removed. If healing occurs before this, the cicatrix soon 
breaks down. 

Where abscesses are allowed to open spontaneously, large, irregular,, 
and usually very intractable ulcers often form. The skin is under- 
mined for a considerable distance, and it has an unhealthy appearance. 




Fig. 143.— Cicatrices following a neglected case of tuberculous adenitis, in a girl seven years- 
old. There is also a tuberculous patch upon the skin of the cheek in a very frequent 
location. 

Such ulcers sometimes continue for many months in spite of all treat- 
ment, particularly if the patient's general health is poor. The scars left 
after them are large and unsightly, and sometimes positively deforming 
(Fig. 143). Their appearance is quite characteristic. They often have 
many tabs of skin attached to them ; they may form prominent ridges 
which may undergo contraction like those after burns ; they are of a pur- 
plish-red colour, and adherent to the deeper tissues. They are often 
sensitive and painful. As time passes they atrophy and become less con- 
spicuous, though they remain through life. 



TUBERCULOUS ADEXITIS. 829 

The general health of children with tuberculous glands may be much or 
little affected, and not a few remain in good condition throughout the 
whole course of the disease, particularly when suppuration does not occur, 
but sometimes even when it is protracted. 

Prognosis. — In no case, I think, does tuberculosis of the external lymph 
glands cause death. Though the course is often protracted, lasting in 
some cases for eight or ten years, ultimate recovery may be confidently 
predicted in the great majority of cases. As stated at the beginning of 
this article, it is a matter of surprise that so few of these children ulti- 
mately develop general tuberculosis. Treves * says, " The percentage of 
those who fall victims to diffused tubercular disease is so small that the 
probability of that disease may be put out of the question," and that to 
urge the prevention of phthisis as an argument for operation " is unwor- 
thy of consideration." Poore f states that of fifty-eight cases, only two 
were known to have died of tuberculosis. Xordan on the other hand 
reports that of 149 cases that were followed, eighteen per cent were known 
to have died from tuberculosis, and nine per cent, though living, were 
suffering from that disease. Although it is certainly infrequent, I can 
not believe such a sequel to be quite so rare as do the two authors quoted. 

Diagnosis. — Tuberculous adenitis is to be distinguished from simple 
chronic enlargement, from that due to syphilis, from Hodgkin's disease, 
and from malignant disease. The diagnostic features of tuberculous 
glands are the age of the patient — usually from three to ten years — the 
site of the primary swelling, the indolent course, the trifling original cause, 
and most of all the disposition to slow caseation, softening, and abscess. 
The cases of simple hyperplasia are usually in children under five years, 
their progress is much more rapid, there is often some definite cause, and 
they have in most cases nearly or quite disappeared in the course of three 
or four months. They suppurate, if at all, during the first month. 
Syphilitic disease is to be recognised mainly by discovering the evidence 
of syphilis elsewhere, and by the effect of treatment. In Hodgkin's dis- 
ease, glandular groups in other parts of the body are involved simultane- 
ously or in rapid succession. There are no signs of inflammation or 
caseation; and the swellings are accompanied by very marked and defi- 
nite constitutional symptoms,— anaemia, emaciation, and general prostra- 
tion. Malignant growths are very rare, they increase rapidly, often attain- 
ing a great size in a few months. 

Treatment— The general treatment of tuberculous glands is to put the 
child under the very best surroundings possible. The seaside has a greal 
reputation for such cases, and no doubt the majority do very well there; 
but some are benefited even more by a dry, mountain climate. At all 
events, a child from the city should be sent into the country whenever 



* Loc. cit., p. 188. I New York Medical Journal, June 88, 1892 



830 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

this is possible. Internally the only remedies which have any special 
virtues are cod-liver oil and the syrup of the iodide of iron. The latter 
should be given in full doses — i. e., twenty or thirty drops, three times a 
day, to a child of six years. Arsenic and iron are useful as general tonics. 
Local applications are of little value and most of them positively harmful ; 
painting with iodine and poulticing should be discarded altogether. The 
parts should be protected against cold, and should be rubbed or handled 
as little as possible. 

It is important in every case to remove from the nose and throat all 
sources of local irritation. Hypertrophied tonsils should be excised, and 
the adenoid tissue of the pharynx scraped out, even when not very exten- 
sive, since these are the two regions which most frequently harbour the 
tubercle bacilli. Any pathological conditions in the nose, such as hyper- 
trophy of the turbinated bodies, should receive attention ; so also should 
chronic otitis, chronic conjunctivitis, carious teeth or ulcers in the mouth. 
All these, if they do no more, keep up a constant glandular irritation, and 
produce conditions which are most favourable for the activity of the tu- 
bercle bacillus. 

Operative measures. — These are indicated if, after two or three months 
of constitutional treatment, the glands affected continue to increase in 
size and number. The advantages of operation over leaving the case to 
Nature are, that it leaves a clean scar instead of a large, irregular one ; 
that it shortens the disease and prevents the long, tedious suppuration of 
cases left to themselves ; that it is a radical measure ; and. that it avoids 
the danger of general infection by removing the tuberculous focus. 

With reference to the choice of operations, surgeons are by no means 
agreed. The indications for the different operations laid down by Treves, 
seem to me to be the best that have been formulated : 

1. Excision and enucleation. — Adapted to cases where there is no ac- 
tive inflammation and no softening ; where the process is very slow and 
indolent ; where there are one or two large, hard glands, or a chain of 
smaller ones, all freely movable and all clearly defined, or where there is 
a single large tumour causing pressure symptoms. 

2. Scooping. — Adapted to glands which have softened and are ad- 
herent, especially to the skin; also where the capsules are thickened. 
This operation should not be done during a period of acute inflamma- 
tion. 

3. Cautery puncture. — Useful both in hard, movable glands and in 
those which are soft and adherent ; particularly adapted to those adherent 
to the skin, and for these it is better than the scoop. It is not applicable 
to glands smaller than a cherry. This operation is done with a small 
cautery point, which is thrust through the skin into the gland, and then 
in two or three directions through it, after which some soothing dressing 
is applied. Although widely used in Europe, this operation is but little 



HODGKIX'S DISEASE. 831 

employed in America, — not so often, it would appear, as it should be, from 
the advantages claimed for it. 

All surgeons agree that in operating, violent tearing out of the glands 
should be avoided ; that as little injury as possible should be done to the 
tissues ; that the capsules should not be torn nor the tuberculous materials 
allowed to escape into the healthy tissues. All agree also that prolonged 
dissections are to be avoided, and that in removing deeply-seated glands 
there is great danger of injuring vessels and nerves and the dome of the 
pleura. 

Glandular abscesses should in all cases be opened as soon as pus 
forms, to prevent the extensive undermining of the skin, which is so likely 
to occur. The opening should be a small one, and all squeezing of the 
gland or surrounding tissues avoided. 

HODGKIX'S DISEASE (ADEXIE). 

This is a rare disease in which there is a general hyperplasia of the 
lymphatic glands throughout the body, with growths of lymphoid tissue 
in the spleen, liver, and other internal organs. It is accompanied by 
marked ansemia, is progressive in its course, and usually terminates fatally. 
The cause is unknown. It is much more common in males than in 
females. Its occurrence in childhood is exceedingly rare. 

The changes in the glands consist in a simple hyperplasia, which may 
be extreme. Suppuration and caseation are very rare, if indeed they ever 
occur. Any of the external or internal groups of lymph glands may be 
affected, and in severe cases the disease may involve almost every chain of 
glands in the body. Of the external groups, the cervical and the axillary 
are usually most affected; of the internal groups, those of the mediastinum 
and the retro-peritoneal region. The spleen and the liver are moderately 
enlarged, and lymphoid growths, varying in size from a pin's head to a 
grape, are usually scattered throughout their substance. There may be 
changes in the bone-marrow. 

Symptoms. — These come on very gradually, often insidiously. The 
external glandular swellings are usually the first noticed, but Bometim 
is the anaemia which first attracts attention; occasionally it is the local 
symptoms resulting from the pressure of internal glands, which maj 
rise to oedema, pain, cough, or dyspnoaa. The progress is generally .-low- 
but steady, and the glands may reach an immense size. The blood shows 
a moderate reduction of the red and an increase in the white cells, par- 
ticularly the lymphocytes (Osier). 

Treatment. — The only remedy which is of much avail in this 
arsenic, which must be given in full doses and for a long time. The gen- 
eral treatment should be tonic. 



832 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

CHAPTER III. 

DISEASES OF THE SPLEEN. 

Weight. — From one hundred and forty observations made at the New 
York Infant Asylum the following were the weights recorded at the dif- 
ferent ages : 

Weight of the Spleen in Infancy and Early Childhood. 



Age. 


Ounces. 


Grammes. 


Birth 


i 

t 
It 
1* 


7-7 


Three months .... 




15-5 


Twelve " ... 




23-2 


Two" years 


38-5 


Three " . 


46-4 







Position and Methods of Examination. — The normal position of the 
spleen is close against the diaphragm, its external surface being opposite 
the ninth, tenth, and eleventh ribs. Its anterior border comes as far for- 
ward as the middle axillary line, its posterior border being usually near 
the vertebral column. In infancy it is practically, impossible to outline 
the spleen "by percussion, unless it is enlarged. During full inspiration 
the spleen is often depressed enough to be felt at the free border of the 
ribs, but at other times it can not be felt unless it is enlarged or pushed 
downward by some pathological condition in the chest. Normally, the 
long axis of the spleen is nearly parallel with the ribs, but when the 
organ is much enlarged, its axis corresponds nearly with a line drawn 
from the axillary line at the border of the ribs to the middle of Pou- 
part's ligament. 

The thin abdominal walls of young children render palpation of the 
spleen much easier than in adults ; and this is a much more satisfactory 
method of examination than is percussion. In fact, the results from per- 
cussion are so uncertain and misleading that in most cases one may 
dispense with it, and rely on palpation to determine the size of the 
spleen. For satisfactory palpation it is necessary that the abdominal walls 
should not be tense. It is therefore important that the child should be 
quiet, and that the examination be made as gently as possible, and no 
force or undue pressure used. The child should lie upon its back with 
the thighs flexed and the skin, of course, bared. The physician, always 
having taken the trouble to warm his hands, should stand upon the left 
side of the patient and make pressure with the tips of the fingers, which 
are semiflexed. The pressure should be at first light and gradually in- 
creased, the fingers being then held stationary during two or three re- 
spiratory movements. It is sometimes better to use the fingers of one 



ENLARGEMENT OF THE SPLEEN. 833 

hand for palpation, and make pressure with the other directly over the 
first. Palpation should be made in the axillary line. If the examination 
is satisfactory, and in the great majority of cases it is so if the child is 
quiet, the spleen can easily be felt when it is sufficiently enlarged to be of 
any diagnostic importance. With a little practice one can readily detect 
even slight degrees of enlargement. 

When moderately enlarged, the lower border of the spleen is an inch 
or so below the free border of the ribs ; when greatly enlarged, it forms 
a tumour which may nearly fill the left half of the abdomen. A tumour 
in the left hypochondriac region is recognised to be the spleen, by the fact 
that it is freely movable laterally and at its lower border or extremity, 
while it is attached above ; also its inner border can usually be felt to be 
thin and sharp, and marked about its middle by quite a deep notch. 

ENLARGEMENT OF THE SPLEEN. 

In Acute Disease. — The spleen is most frequently and most constantly 
enlarged in malarial and typhoid fevers, but it is occasionally so in all 
the acute infectious diseases. 

In most of these cases the enlargement is chiefly from congestion, but 
there may be acute hyperplasia and an increase in size of the Malpighian 
bodies. It may contain small haemorrhages, and in extremely rare cases 
the spleen may rupture. In appearance it is generally dark-coloured, 
soft, and somewhat friable. In the cases which recover, the splenic swell- 
ing subsides with the original disease. 

In Chronic Disease. — Like the lymph nodes, the spleen is much more 
often enlarged in children, particularly young children, than in adults. 
Enlargement is seen at times in almost all the chronic diseases of early 
life ; but it occurs most frequently in rickets, syphilis, malaria, tubercu- 
losis, the blood diseases, and in amyloid degeneration. Besides, it may 
be the seat of primary disease, either simple or malignant. 

Rickets. — The splenic enlargement which accompanies rickets is gen- 
erally seen during the first year; at this period it is very frequent. The 
swelling is usually moderate, but occasionally it is so great that the lower 
border is three or four inches below the ribs. It belongs to the most 
severe forms of the disease. 

Syphilis. — Enlargement of the spleen is one of the most constant 
lesions in congenital syphilis. It is present with great uniformity in chil- 
dren born with syphilitic lesions, and very frequently during the active 
period of the disease in early infancy. It is seen at a later period during 
infancy or childhood, associated with other late symptoms. The degree 
of enlargement is often great. In several cases I have Been it sufficient to 
form a large abdominal tumour. The liver also is increased in Bize, but 
not to such a degree. The pathological changes in tin- Bpleen in syphilis 

are considered with that disease. 
62 



£34 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

Kiittner * has made a study of the blood in cases of hereditary syphilis 
and rickets that were accompanied by splenic enlargement. The num- 
ber of red cells was found to vary greatly, as did also their ratio to the 
white cells. 

Malaria. — The swelling in these cases may be very great. The liver 
is not so often enlarged as in syphilis. There is usually a history of ex- 
posure in a malarial district. 

Tuberculosis. — It is rare to find anything more than a moderate swell- 
ing of the spleen in tuberculosis. In the most acute cases this may be 
due to the fever and general infection ; in those which are less rapid, it 
depends either upon tuberculous deposits or passive congestion from 
venous obstruction, the result of the pulmonary disease. 

The blood diseases. — Marked enlargement of the spleen is found in 
many cases of simple anaemia accompanied by moderate leucocytosis. 
This is quite peculiar to infancy and early childhood. The spleen is con- 
stantly swollen, and usually greatly so, in the pseudo-leucaemic anaemia of 
infants, in leucaemia, and in Hodgkin's disease. In the last two diseases 
the liver is also enlarged, but to a much less degree than the spleen ; in 
the others it is but slightly changed. 

Amyloid degeneration. — The causes of this condition and its general 
symptoms are mentioned in connection with amyloid disease of the liver 
(page 413). The spleen is constantly involved, and the enlargement of 
this organ, as well as that of the liver, may be very great. The changes 
resemble those found in the liver. 

Cardiac disease. — In all forms of cardiac disease, and in other con- 
ditions in which there is obstruction to the systemic venous circulation, 
the spleen is enlarged. It is seen in congenital as well as in acquired 
cases. The liver is usually enlarged to about the same degree as the spleen, 
and there may also be dropsy of the feet. 

New-growths, tumours, etc. — In rare cases in early life, the spleen is the 
seat of new-growths ; these are usually varieties of sarcoma, but carcinoma 
has also been reported. Lymphoma, or, as it is more properly called, sim- 
ple hyperplasia of the spleen, has occasionally been observed in early life, 
apart from any of the constitutional diseases above mentioned. 

Acker (Washington) has reported a remarkable case in a coloured boy 
of eight years, who died of scarlet fever a year after the splenic tumour 
was first noticed. At the autopsy the spleen weighed fifty-two ounces. 
There was found a very great degree of hyperplasia, but nothing indicat- 
ing malignant disease. 

Echinococcus of the spleen has been reported in Europe, but none, so 
far as I am aware, in America, among children. 

* Jahrbuch fiir Kinderheilkunde, Bd. xxxv, H. 2. 



ACUTE ARTHRITIS OF INFANTS. 835 

CHAPTER IV. 

DISEASES OF THE BONES AND JOINTS. 

ACUTE ARTHRITIS OF INFANTS. 

The term acute arthritis of infants has been given by Thomas Smith, 
Townsend,* and others, to a form of joint inflammation which is peculiar 
to infancy and not very rare at this time. It has been described under 
the names of acute purulent synovitis of infants, acute epiphysitis, 
pyamiia of bone, acute osteo-myelitis, etc. The disease is essentially a 
form of pyaemia, and is a suppurative process almost from the outset. 
It may begin at the epiphyseal junction, in the medullary canal, or in 
the joint ; usually, however, the joint is invaded secondarily, the disease 
sometimes spreading to it with great rapidity from the bone. It may also 
result in a diffuse osteo-myelitis or in a subperiosteal abscess. Secondary 
abscesses may form in the viscera or in distant articulations. As a con- 
sequence of the disease, there may be separation of the epiphysis from the 
shaft, sometimes entire destruction of the articular extremities of the bone 
or articular cartilages. As late results there may be a pathological dislo- 
cation, or a " flail joint " ; less frequently there may be anchylosis. The 
extent of the ravages in the joint structures depends chiefly upon the 
duration of the process. Where the pus is evacuated early, recovery may 
take place with very little permanent damage ; but in neglected cases com- 
plete destruction of the joint often occurs. 

Etiology. — Of 73 cases collected by Townsend, all but four occurred 
during the first year of life, and over half of them during the first three 
months. These early cases have already been mentioned among the 
Pyogenic Diseases of the Newly-Born (page 82). So far as is known, the 
disease has no relation either to syphilis or tuberculosis. There is in 
some cases a history of traumatism, but this can only play the role of an 
exciting cause. The essential cause of the disease is the entrance of 
pyogenic germs into the circulation. They may gain admission through 
the umbilicus, some abrasion of the skin, or the conjunctiva (paps 79, 
80). Very often the source of infection cannot be discovered. Cases 
occurring later than the first few months of life have sometimes followed 
measles, scarlet fever, or empyema. 

Symptoms. — The onset is often sudden, with well-marked local and 
constitutional symptoms. The disease may be ushered in with a chill, 
followed by a fever, which is frequently high, fluctuates widely, and is 
accompanied by general prostration, restlessness, and other signs of pain. 



* W. R. Townsend, M. P., American Journal of the Medical Sciences, January, i v, ."». 

Here will be found a full discussion of the subject, and the bibliography. 



836 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

There is rapid swelling about the affected joint, which is usually diffuse, 
as the lesion is deep-seated. There is also acute tenderness, and usually 
deformity. Later there are redness, oedema, a glazed skin, and deep fluc- 
tuation. In some cases the constitutional symptoms are slight or wanting. 
After pus forms, it may lead to rupture of the capsule and infiltration of 
all the tissues about the joint, often burrowing for a considerable distance 
before it reaches the surface. 

When its progress is most rapid, death may occur in two or three days, 
from exhaustion or general pyaemia. The lesions in such cases are usually 
multiple. The usual duration is from one to two weeks, suppuration 
generally being evident in four or five days. In Townsend's collection of 
cases the joints were affected in the following order : hip, in 38 cases ; 
knee, in 27 ; shoulder, in 12 ; wrist, in 5 ; elbow, in 4 ; ankle, in 4 ; fingers, 
in 2 ; toes, in 1 ; sterno-clavicular, in 1. I have met with one case in which 
suppuration occurred in the temporo-maxillary and the medio-sternal 
joints; in another, in the temporo-maxillary and shoulder. In 75 per 
cent of the cases collected by Townsend only one joint was involved, and 
of these two thirds recovered ; in the remaining 25 per cent, with multi- 
ple joint lesions, only one fourth of the cases recovered. Of those who sur- 
vive the acute period, the number who recover with perfect joints is small. 

Diagnosis. — The disease is not usually difficult of recognition, from 
the constitutional symptoms, the marked swelling, tenderness, and de- 
formity, and the rapidity with which suppuration occurs. It has been 
mistaken for rheumatism, although rheumatism is so rare in infancy that 
it may be practically ignored. Syphilitic epiphysitis resembles it in the 
localized pain, tenderness, and general immobility, but lacks the rapid 
swelling, fever, and severe constitutional symptoms, and its course is more 
prolonged. Acute cellulitis in the neighbourhood of the joints may 
resemble it, but this is rare except from traumatism. The disease has 
little in common with tuberculous bone disease of later childhood. 

Treatment. — The general treatment is to be directed toward the 
patient's condition, and the purpose of it should be to relieve pain and 
support the general strength. Suppuration occurs very early, and no 
time should be wasted in trying to allay the inflammation by local appli- 
cations. The best results are obtained by early incision, free drainage, 
and thorough antiseptic treatment. Fixation of the joint should follow 
operation, in order to prevent deformity. 

THE TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 

The chronic forms of tuberculous bone-disease, on account of their 
insidious onset and the frequency with which they simulate other diseases, 
more frequently fall, in the early stage at least, into the hands of the 
physician than into those of the general or orthopaedic surgeon. All 
that will be attempted in this chapter will be to outline in a general way 



TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 837 

the most important forms — viz., disease of the vertebrae, hip, and knee — 
dwelling particularly upon the early symptoms and diagnosis. For their 
fuller discussion, particularly as to the details of treatment, the reader is 
referred to text-books on general or orthopaedic surgery. The causes are 
the same, and the lesions are very similar in all forms, and will therefore 
be considered together. 

Etiology. — The age at which tuberculosis of the bones most frequently 
begins, is from the third to the eighth year, it being comparatively rare 
before the end of the second year. The sexes are affected with about 
equal frequency. Tuberculous bone disease may occur in a child who has 
previously been in apparent health, but more often in one who has been 
reduced by some previous illness, especially the infectious diseases of child- 
hood ; of these, it most frequently follows measles and whooping-cough. 

A history of inherited tuberculosis is present in a large number, but 
by no means in a majority of the cases. Like tuberculosis of the cervical 
glands, it is rarely preceded by other tuberculous processes, although it 
may be followed by them. It usually appears as an example of primary 
infection ; but it seems very improbable that such should actually be the 
case. It is more likely that there has previously been a latent focus of 
tuberculosis elsewhere in the body. In many cases, antecedent disease of 
the bronchial glands has been demonstrated by autopsy. Infection from 
these or from other tuberculous lymph glands, is the most probable 
explanation of the origin of infection in cases of bone disease. However, 
by some writers, notably Baumgarten, tuberculous disease of bone is 
regarded as due to direct inheritance, and is to be compared to the bone 
lesions which occur as late manifestations of hereditary syphilis. 

Traumatism is often an exciting cause, and it may determine the 
site of the disease. 

Lesions. — The tuberculous joint diseases of childhood are, as a rule, 
secondary to disease of the bones. Hip- joint disease usually begins in the 
head of the femur, and knee-joint disease in one of the condyles ; ankle- 
joint disease in the lower epiphysis of the tibia, etc. 

The frequency with which disease is seen in the different locations is 
shown by the following table, which gives the Dumber of cases of each 
form applying for treatment at the Hospital for Ruptured and Crippled, 
New York, during the years 1884 to 1893 inclusive: 

Spi ne 2,145 cases, or 87'5 pel Oent 

Hip..!!'.!! 1,937 " - W-O » 

Knee 1,222 31'5 » 

Ankle or tarsus 265 I » 

Elbow 71 » " L'2 " 

Wrist 50 " M 0-9 " 

Shoulder 24 - « (H « 

Total 5,704 LOO'O 



838 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

The character of the bone disease upon which chronic joint disease de- 
pends is generally a primary ostitis, which affects the articular extremities 
of the long bones usually beginning near the epiphyseal line ; in the short 
bones it is a central ostitis. The stages in the process are first congestion, 
swelling, and cell infiltration, followed by caseation, and frequently by 
softening and suppuration. In the early stage, the bone is slightly en- 
larged, and on section one or more yellowish foci of disease are seen. The 
disease may be arrested in this stage, encapsulation of the inflammatory 
products taking place ; or it may continue until there is a more or less 
extensive breaking down or disintegration of the affected bone. As the 
disease extends there are involved, the periosteum, the articular cartilage, 
and finally the joint itself. Abscess may form in the joint or in the soft 
parts surrounding the bone. The process is quite analogous to tuberculous 
disease of the lung. As the disease advances ligamentous attachments are 
loosened, and displacement of the parts occurs with the production of 
deformity, due partly to muscular contraction and partly to the weight of 
the body. The inflammatory process with its resulting disintegration 
generally goes on to a certain point, where it is arrested. Gradually the 
broken-down bone substance is separated and thrown off in small particles 
in the discharge, and a reparative process begins, with the formation of 
healthy bone. Where joint structures have been destroyed, cure takes 
place by bony anchylosis. Sometimes the disease finds its way to the 
surface without involving the joint ; at other times the disease may be 
arrested, and its products become encapsulated within the bone. Inflam- 
mation of the joint may occur by a gradual extension of the inflammatory 
process, or by a sudden perforation of the articular lamella. As a result 
of extensive disease, all the joint structures may be affected, — the synovial 
membrane, ligaments, articular cartilages, and the cellular tissue surround- 
ing the joint. The process of disintegration and that of repair are both 
very chronic and measured by months or years. The entire course of the 
disease is from one to ten years, three years being about the average dura- 
tion. In the great proportion of cases but one joint is involved, although 
it is not infrequent in hospitals to see two, three, and sometimes four of 
the large joints affected in the same patient. 

Secondary lesions. — Abscesses form in a considerable proportion of 
the cases, and often burrow a long distance before they reach the surface. 
Amyloid degeneration of the liver, spleen, and kidney, and sometimes of 
the villi of the intestines, occurs as the result of the prolonged suppura- 
tion, chiefly in connection with disease of the hip or spine, occasionally 
with that of the knee. General or localized tuberculosis, particularly 
tuberculous meningitis, may develop at any time and prove fatal. 

Caries of the Spine — Pott's Disease. — This consists in a chronic 
inflammation of the bodies of the vertebrae, usually beginning in the cen- 
tral portion and extending to the periosteum, ligaments, cartilages, and, 



TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 



839 



in fact, to all the contiguous structures. It frequently involves the mem- 
branes of the cord, the roots of the spinal nerves, and even the cord itself. 
The number of vertebrae usually affected is from two to five. The gross 
appearance of the lesion in a well-marked case is shown in the accompany- 
ing cut (Fig. 144). After the bodies of the vertebrae have become soft- 
ened and partially broken down by disease, the pressure from the super- 
incumbent weight of the body causes them to fall together and produces 
a backward displacement of the spinous processes, giving rise to the de- 
formity known as kyphosis, which in its ex- 
treme form is popularly known as " hunch- 
back." 

Any part of the vertebral column may be 
affected ; but the disease is most frequent in 
the dorsal region, as shown by the following 
statistics from the Hospital for Ruptured and 
Crippled : of 2,143 cases, 72*5 per cent affected 
the dorsal region, 15*3 per cent the lumbar 
region, and 12*2 per cent the cervical region. 

Symptoms. — The onset is gradual, often in- 
sidious, and the early symptoms are frequently 
overlooked or misinterpreted. The case may 
go on for weeks or even months before the 
true nature of the disease is recognised, which 
is often not until deformity has occurred. In 
nearly all cases, however, the early symptoms 
are sufficiently characteristic to enable a care- 
ful observer to make a diagnosis before the 
stage of deformity. 

The most constant early symptoms are : (1) 
pains caused by the irritation of the nerve 
roots and referred to various parts of the body, 
following the distribution of the spinal nerves ; 
(2) rigidity of the spine from muscular spasm, 
this being an attempt to prevent motion at 

the seat of disease; and (3) the assumption of various postures calculated 
to relieve pressure upon the diseased vertebral bodies. Sometimes the first 
symptoms are those of pressure-paralysis (page 768); at others they are 
the local signs of abscess. In addition to the local symptoms mentioned, 
there is usually disturbed sleep, often accompanied by moaning. 

Cervical disease. — The pains are often fell above the point of disease, 
frequently in the form of occipital neuralgia ; sometimes they are referred 
to the front or the side of the neck. They may be bo frequent and so 
severe that the face assumes a constant expression at anxiety or dial 
In other cases pain is excited only by an at tempt at movement The 




Fig. 144.— Pott's disease of the 
upper dorsal region ; a ver- 
tical section of the spine, 
Bhowing disintegration or the 
bodies of the vertebra and 
encroachment upon the spinal 
canal. | From a patienl dying 
in the Hospital tor Ruptured 
and Crippled. I 



840 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

muscular spasm most frequently takes the form of slight torticollis, some- 
times of slight opisthotonus; sometimes there is simply a fixation of the 
head by a tonic spasm of all the muscles of the neck ; both active and 
passive motion is resisted, and any movement may be so painful that the 
child involuntarily steadies its head with its hauds. These symptoms 
come on gradually and are persistent. Sometimes they are overlooked, and 
the first thing to attract attention is a progressive weakness in the lower 
extremities, which proves the beginning of paraplegia. Occasionally the 
first marked symptoms are those due to the formation of a retro-pharyn- 
geal or a retro-oesophageal abscess (page 276). 

The deformity from cervical disease develops much later than when 
the disease is located elsewhere. Usually the neck appears broadened or 
thickened in a nearly uniform way, and often the head seems to have 
settled downward upon the shoulders. In the lower cervical region, a 
kyphosis is not infrequent ; but in the middle and upper regions there is 
more often an anterior prominence, which may be felt in the posterior 
wall of the pharynx. 

Dorsal disease. — The referred pains are now below the seat of disease,, 
and take the form of intercostal neuralgia or pain in the epigastrium or the 
abdomen. They are often ascribed to cold, malaria, indigestion, or worms. 
There is a disposition to assume the prone position while sleeping, and 
also to lean across a chair or the lap of the nurse. The child walks care- 
fully, holding the spine erect and very stiffly, and exhibits great caution 
in getting into or out of bed, or in rising from a recumbent position. In 
the beginning there may be a slight lordosis, or forward curve at the seat 
of disease, instead of the usual kyphosis or backward projection, but the 
latter soon takes its place, and with it is seen the compensatory lordosis in 
the lumbar region. 

Lumbar disease. — The first symptoms here are often pain and lame- 
ness, referred to one of the lower extremities. This frequently leads to 
the suspicion that the hip is the seat of disease. In addition to the lame- 
ness there may be a tilting of the pelvis to one side, and sometimes quite 
a distinct lateral curvature of the spine. Eef erred pains are not so fre- 
quent nor so severe as when the upper part of the spine is affected ; they 
may be felt in the groin, in the loin, in the thigh, in the buttock, or in 
the hypogastrium. The gait and attitude are very characteristic : throw- 
ing the shoulders well back, the patient walks stiffly with short steps, 
holding the spine with the greatest care. He rises from the floor awk- 
wardly and with difficulty. Deformity is not usually so early or so 
marked as when the disease is dorsal, and often before it is visible there 
are symptoms due to the formation of psoas abscess, — lameness, flexion of 
one thigh, and a tumour may be found deep in the iliac fossa or at the 
upper and inner aspect of the thigh ; in both locations it has often been 
mistaken for hernia. 



TUBERCULOUS DISEASES OP THE BONES AND JOINTS. 841 

Physical examination. — Whenever any of the above symptoms are 
present, the child should be stripped and submitted to a thorough exami- 
nation, the purpose of which should be to determine, first, the existence of 
any deformity ; secondly, the mobility of the spine ; thirdly, the presence 
of any secondary lesions, such as abscesses or paralysis. The mobility of 
the spine is best determined by studying the attitude, gait, and posture of 
the child, and the manner of stooping or rising from the floor. The gait 
has already been described with the symptoms of lumbar disease. As it 
has been tersely put, " the child walks with its legs but not with its back." 
In stooping, the same disinclination to bend or move the spine is seen. 
It is often impossible to induce the child to stoop at all, and when it does 
so, to pick up some object, there is acute flexion at the knee and hip, but 
as little bending of the spine as possible. In rising from the recumbent 
position the same thing is seen. The posture and attitude of the child 
will be modified by the position of the disease, and somewhat by the ac- 
tivity of the process at the time ; however, by comparing the movements 
referred to with those of a healthy child, the great difference will at once 
be apparent. If the symptoms point to cervical disease, a digital explora- 
tion of the pharynx for deformity or abscess should be made, and the 
extremities should be examined for paralysis. If the disease is in the 
lumbar region, deep palpation of the iliac fossa should be made to discover 
a psoas abscess, and the passive movements of the thigh should be carefully 
tested to determine whether there is any resistance to extreme extension, 
this often being present before the psoas tumour. No matter how clearly 
the lameness may be at the hip, it should be remembered that this often 
results from disease of the lumbar spine. If the thigh is flexed and freely 
movable except in extension, the symptoms are probably the result of 
psoas irritation, for in hip-joint disease the other movements of the joint 
are also resisted. 

The deformity of Pott's disease is often spoken of as " angular " curva- 
ture of the spine. While this is a true description of the disease ;ii an 
advanced stage, there is often in the early stage only a general curve. 
Later a slight knuckle is seen from the unnatural projection of a single 
spinous process. This deformity may increase and finally involve five or 
six vertebrae. It is usually greatest in the upper dorsal region. A Blight 
prominence, which does not disappear on suspending the patient, is always 
suspicious. 

Tenderness upon pressure over the spinous processes and inn 
sensitiveness to heat and cold, are rarely present. Pain may sometimes 
be produced by downward pressure upon the bead or Bhoulders in the axis 
of the spine. This symptom is not necessary for diagnosis, and the at- 
tempt to elicit it is strongly condemned byGibney, who has seen Berions 
harm follow such a test. 

Course of the disease. — Caries of the spine is a very chronic disease, its 



842 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

course being measured by months or years, but marked, as in all chronic 
diseases, by periods of remission and exacerbation. An exacerbation may 
follow traumatism, and is often accompanied by the formation of an ab- 
scess. After the disease has lasted from one to three years, the destructive 
inflammation ceases and repair begins, a cure being finally effected by a 
process of consolidation of the fragments of the diseased vertebrae, and the 
production of anchylosis. Relapses are easily excited by traumatism, by 
improper treatment or by discontinuing the use of mechanical supports 
before the disease is arrested. 

Abscesses. — The frequency with which abscesses occur depends some- 
what upon the treatment. Townsend states that of 380 cases, abscess was 
present in 20 per cent. They are rarely seen earlier than three or four 
months from the beginning of symptoms, and usually belong to the sec- 
ond year of the disease. They sometimes form with acute symptoms, but 
more frequently they appear as typical cold abscesses. Those connected 
with cervical disease are retro-pharyngeal or retro-cesophageal, or they 
may open externally, usually just above the clavicle, in front of the sterno- 
mastoid muscle. Those with disease of the lower cervical and upper dorsal 
vertebrae, are apt to burrow along the spine, appearing in the lumbar re- 
gion ; rarely they may rupture into the oesophagus or the pleural cavity. 
Those with disease of the lower dorsal or lumbar vertebrae, may open just 
above the iliac crest posteriorly, or burrow anteriorly between the abdomi- 
nal muscles, but the usual course is for them to follow the psoas muscle, 
appearing in the groin just above Poupart's ligament or at the upper and 
inner aspect of the thigh. 

Paralysis occurs in about one half the cases in which the disease affects 
the lower cervical and upper dorsal vertebrae, but it is rare when the dis- 
ease is below the middle dorsal region (see Compression Myelitis, page 768). 

Prognosis. — The actual mortality of Pott's disease is difficult to state, 
so many of the consequences of the disease being remote and not fully 
appreciated until adult life is reached. The general mortality from all 
causes is from ten to twenty per cent. The causes of death are exhaus- 
tion from prolonged suppuration, amyloid degeneration, myelitis, general 
tuberculosis, and tuberculous meningitis. Sudden death occasionally oc- 
curs from pressure upon the cord in the upper cervical region, or from the 
pressure effects of abscesses in the posterior pharynx or in the posterior 
mediastinum. 

The prognosis as to the amount of permanent deformity, will depend 
upon the seat of the disease, the time at which treatment is begun, and 
upon the thoroughness with which it is carried out. The best results as 
to deformity are obtained when the disease is below the middle dorsal re- 
gion. With improved methods of treatment begun early, a large number 
of these patients recover with an insignificant amount of deformity, and 
some with none whatever. 



TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 843 

Diagnosis. — The spinal deformity resulting from Pott's disease may be 
confounded with rachitic kyphosis or with rotary lateral curvature. Rachitic 
curvatures (page 225) are usually seen in children under eighteen months 
of age, a time when Pott's disease is rare ; there are other signs of rickets 
present, and instead of rigidity there is usually undue mobility of the spiue. 
What is true of rickets may be said of all curvatures depending upon mal- 
nutrition. Rotary lateral curvature is seen about puberty, rarely in young 
children except in connection with rickets. A slight lateral deviation of 
the spine, sometimes seen in the early stage of caries, may resemble a case 
of incipient rotary curvature. The latter is not attended by pain or rigidity, 
and is most frequent in young girls from eleven to fourteen years of age. 

Other abscesses may be mistaken for those dependent upon vertebral 
caries. This difficulty is likely to exist in the cases attended by very 
little spinal deformity. These abscesses are most frequently in the iliac 
fossa or in the lumbar region, and may be due to perinephritis or ap- 
pendicitis. The latter are more acute than those depending upon bone 
disease and usually accompanied by fever. Tumours of the vertebrae or 
of the spinal cord may give rise to symptoms almost identical with those 
resulting from compression myelitis due to Pott's disease, but both of 
these are extremely rare. 

Treatment. — The treatment of Pott's disease is both general and local, 
and neither should be neglected. The constitutional treatment should be 
similar to that employed in other forms of tuberculosis. 

The indications for local treatment are to put the diseased parts at 
rest, by immobilizing the spine and removing the superincumbent weight 
of the body. With the great advances made in orthopaedic surgery it is 
no longer necessary to confine these patients in bed, as was formerly prac- 
tised, to secure this result. It may be accomplished either by plaster-of- 
Paris, or some other form of jacket, or a properly fitting steel brace. A 
head-support should be attached to all forms of apparatus, if the disease 
is above the middle dorsal region. The closest attention to details and 
much experience in the use of apparatus are required to secure the best 
results. In perhaps no class of cases has the beneficial results of mod- 
ern scientific treatment been more apparent than in those of Pott's dis- 
ease. For the details in regard to the mechanical treatment and the 
different forms of apparatus, the reader is referred to works on general 
or orthopaedic surgery. 

Articular Ostitis of the Bip- -Hip-Joint Disbasi Morbus 
Coxarius. — In early childhood this generally hegina as a chronic ostitis 
in the head of the femur, starting near the epiphyseal line. Exception- 
ally, and according to Gibney, of tener in older children, it begins in the 
acetabulum. The pathological process, as well as the clinical history, is 
generally described as consisting of three Btages. In the firsl Btage- thai 
of ostitis— the lesions are limited to the bone; in the second stage— that 



844 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

of arthritis — all the-joint structures are involved, and in this stage suppu- 
ration usually occurs ; in the third stage there are breaking down and ab- 
sorption of the head and sometimes of the neck of the femur, which, with 
destruction of the ligaments, leads to marked displacement of the parts 
from muscular contraction. The disease may be arrested in the first or 
in the second stage, or it may continue through all three stages. 

Symptoms. — Clinically, the usual duration of the first stage is three or 
four months ; it may last only for a few weeks, it may extend over two 
or three years, and the disease may be arrested in this stage. The onset 
is usually very gradual, and the symptoms are often considered of trivial 
importance until they have continued for some weeks. Generally the first 
thing noticed is slight lameness, due to stiffness of the joint. In the 
beginning this may be seen only in the morning, wearing off during the 
day. It may be accompanied by some tenderness about the hip and a dis- 
inclination to walk. A little later the child complains of pain, which is 
most frequently referred to the front of the knee or the inner aspect of 
the thigh, but only in rare cases to the hip itself. This is slight at first, 
but gradually increases in frequency and severity, and soon there are 
added the " starting pains " at night, which are one of the most character- 
istic features of early hip-disease. These pains are produced by a sudden 
spasm of the muscles during sleep. The child often cries out sharply 
without waking, sometimes wakes with a cry ; this is often repeated sev- 
eral times during the night. Soon restlessness and fretfulness during the 
day are present. The lameness, which at first was slight and occasional, 
or noticed only in the morning, comes to be a constant symptom, and 
week by week increases in severity. The evolution of these symptoms 
may take only a few weeks, but sometimes they come and go in the most 
inexplicable manner during a period of several months, or even one to 
two years, before they are fully developed. 

Physical examination. — Every child with a suspicious lameness, or 
with pains like those mentioned, should be stripped and submitted to a 
thorough examination. The first points to be observed on inspection re- 
late to the general contour of the hip ; every prominence and depression 
should be carefully noted. Then the attitude and gait should be studied ; 
and finally all the functions of the joint should be carefully tested, and 
the limbs measured, to determine the existence of shortening or atrophy. 
At every step a comparison should be made with the sound limb. The 
contour of the hip is changed quite uniformly : there are broadening and 
flattening of the whole gluteal region ; the trochanter is unnaturally 
prominent; the gluteal fold is shortened, and often single instead of 
double. There is no characteristic position of the limb in this stage. 
There is atrophy of the thigh and often of the calf. In Fig. 145 is shown 
the appearance of a typical case in the full development of the first stage. 
In walking, the child favours the diseased side, throwing the weight as 



TUBERCULOUS DISEASES OF THE BOXES AND JOINTS. £45 



much as possible upon the sound limb ; but all these symptoms are of 
much less importance for diagnosis than is an examination of the func- 
tions of the joint. 

For this purpose the child should be placed upon a table upon its 
back, and the various movements of the hip — abduction, adduction, flexion, 
extension, and rotation — should be executed, first with the sound limb 
and then with the suspected one, the two being 
carefully compared at every point to determine 
the degree of motion allowed. It is not neces- 
sary that force should be employed or pain in- 
flicted. If the symptoms have existed for some 
weeks, there is generally a limitation of motion 
at the hip in all directions, but first usually in 
abduction, rotation, or extension. In more ad- 
vanced cases, no motion whatever may be per- 
mitted at the joint, the pelvis tilting with the 
slightest movement of the femur. This fixation 
of the hip is due to tonic muscular spasm. 
Crowding the articular surfaces together, by 
pressure upon the heel or trochanter, produces 
pain, which is usually referred to the joint. 
This test should be carefully, made, lest injury 
be inflicted. Gibney cautions against examina- 
tions under ether, since in this way serious in- 
jury may be done unconsciously. 

Second stage. — This has been called the stage 
of arthritis. Its existence may be assumed when 
the limb takes the position of marked perma- 
nent deformity, which is due at this period to 
muscular action, not to destructive bone changes. 
The transition from the first to the second stage 
is in most cases a gradual one, and the line be- 
tween the two can not be sharply drawn. Some- 
times, however, it is rapid, and marked by a 
sharp exacerbation of all the symptoms. This 
may indicate a sudden perforation of the joint, 

and the rapid development of suppurative arthritis. Such is the usual 
result when an abscess which has been slowly forming in the bone, opens 
into the joint; or acute joint inflammation may be limited up without 
so evident a cause. Sometimes the pus reaches the Burface below the 
capsular ligament, and the joint remains intact. An acute exacerba- 
tion is indicated by increased pain, excessive tenderness abont the hip, 
often by inability to walk, or even to bear any weight upon the limb, and 
frequently by fever. The position assumed by the limb is now fairly 




Fig. u."'. Hip joint dim 
the end of the first 
Bhowing muscular atrophy, 
prominence of the trochan- 
ter, flattening of the gluteal 
region, and a single gluteal 
fold. 



846 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

characteristic. The foot is generally everted, the thigh slightly flexed and 
rotated outward, and the limb apparently lengthened. There may be 
infiltration anywhere about the hip, due to the formation of an abscess. 
The muscular spasm is so great that the joint is locked, — no motion 
whatever being allowed. Abscesses may form at any point about the 
hip; they are especially frequent at the upper and outer aspect of the 
thigh, and may burrow long distances before reaching the surface. The 
duration of the second stage also is indefinite, but it usually lasts from a 
few months to a year, or the disease may be arrested in this stage. 

Third stage. — There is now marked deformity, which is the result of 
muscular contraction after absorption of the head and sometimes the 
neck of the femur, and destruction of the ligaments. The position of 
the limb is a very constant one, and resembles that present in dislocation 
upon the dorsum of the ilium. There is shortening of from one to four 
inches ; the thigh is strongly flexed, adducted, and rotated inward, and 
the foot is inverted ; the trochanter lies against the outer surface of the 
ilium, and is above Nelaton's line. In this position the joint may be- 
come anchylosed. The displacement usually comes on gradually, but it is 
sometimes so sudden as to be mistaken for a true dislocation, although 
the latter is exceedingly rare in the course of hip-disease. 

There is now marked atrophy of all the muscles of the limb, and the 
thigh may be two or three inches smaller than its fellow. JSTo motion at 
all is usually allowed at the hip, but this is compensated for to some degree, 
by the exaggerated mobility of the lumbar spine. The spinal curvature — 
lordosis — is very marked both upon standing and walking. The duration 
of this stage may be several years. From time to time exacerbations oc- 
cur, often excited by falls, and accompanied by the formation of new ab- 
scesses. In protracted cases, all the soft parts about the hip may be seamed 
with cicatrices from old sinuses. After the disease has gone on to the 
third stage, cure can take place only by anchylosis. 

Diagnosis. — The important point in the early diagnosis of ostitis of 
the hip, is the gradual evolution of the symptoms, the most characteristic 
of which are lameness, starting pains at night, and impairment of all the 
functions of the joint. Mistakes in diagnosis most frequently arise from 
a failure to obtain a careful history, and from relying too much upon the 
symptoms of lameness and deformity. The essentially chronic character 
of the disease should constantly be borne in mind. In the vast majority 
of cases, with a careful history, and a thorough examination, there can be 
but little doubt as to the diagnosis except at the very outset. The propor- 
tion of obscure and irregular cases to those following the regular course, is 
small. 

In the early stage, hip- joint disease may be confounded with a strain of 
the joint, with muscular rheumatism, poliomyelitis, periostitis of the shaft 
of the femur, phlegmonous inflammation in the neighbourhood of the 



TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 847 

joint, or with caries of the lumbar spine. In the second stage there is 
even less difficulty in diagnosis, although abscesses resulting from perine- 
phritis or appendicitis have been mistaken for those arising from hip-dis- 
ease. In the third stage, a mistake is almost impossible. 

Prognosis. — This is to be considered both with reference to life and 
limb. The records of the Hospital for Euptured and Crippled show the 
mortality of hospital patients with hip-disease to be nearly 25 per cent. 
This includes deaths directly or indirectly traceable to the disease. The 
causes are nearly the same as in caries of the spine, — exhaustion from pro- 
longed suppuration, amyloid degeneration, and general tuberculosis or 
tuberculous meningitis. 

Under the most favourable conditions, the disease may be arrested in 
the first stage, and recovery occur without lameness or any noticeable im- 
pairment of the joint functions. This result, however, is not often ob- 
tained, because the disease is usually well advanced before it is recognised, 
or because of the difficulty in the way of carrying out all the details of 
treatment in the best possible manner. If the disease has advanced to the 
second stage, and suppuration has occurred, there always results some im- 
pairment of the joint functions ; usually there are decided lameness and 
marked muscular atrophy, but very little shortening or deformity, provided 
the limb has been kept in the proper position. If the disease has ad- 
vanced to the third stage, there are always marked shortening, deformity, 
and lameness. 

Treatment. — The indications for constitutional treatment are the same 
as in caries of the spine. The purpose of local treatment is to secure con- 
stant and complete rest for the diseased parts, and to prevent deformity. 
Rest is secured by overcoming the muscular spasm by means of extension, 
by immobilizing the joint, and by transferring the weight of the body, in 
walking, from the hip to the perinaeum. All these indications are no* 
met, while the patient is up and about, by the use of the most approved 
apparatus. Formerly, rest and immobilization could be secured only by 
keeping the patient in bed, with the use of the weight and pulley. The 
general opinion of orthopaedic surgeons at the present day is againsl 
excision, except in cases where, in spite of treatment by apparatus, the 
disease has advanced to the third stage, and in cases where life is threat- 
ened from prolonged suppuration and exhaustion. Under these con- 
ditions, excision should be performed; but early excision gives results 
very much inferior to those obtained by mechanical and constitutional 
treatment. 

Articular Ostitis ob the Knee - Kheb-Joint Disease — White 
Swelling. — Ostitis of the knee usually begins in one of the condyles ol 
the femur, the inner much oftener than the outer one; less frequently it 
begins in the head of the tibia The pathological process is very much 
like that at the hip. There is in the first stage a central ostitis accom- 



848 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

panied by infiltration and expansion of the part of the bone affected. 
The disease may remain limited to the bone, the inflammatory products 
becoming encapsulated, or softening and breaking down may occur, with 
the formation of an abscess. Gradually the process extends outward, and 
the periosteum and the soft parts are involved. The disease may invade 
the joint itself in a destructive inflammation, or pus may escape externally 
without seriously involving the joint structures. The degree to which the 
joint is involved, varies much in different cases ; there may be only a sim- 
ple synovitis, a suppurative arthritis, or a destruction of the cartilages 
and articular ends of the bones, synovial membrane, and ligaments, so 
that in the advanced stage all traces of a joint structure are lost. 

If the process remains limited to the bone, recovery may take place 
with very little impairment of the joint functions. If suppuration in the 
joint has taken place, there will be more or less stiffness and fibrous or 
bony anchylosis. When there is destruction of the ligaments and articular 
ends of the bones, the limb assumes a characteristic position, — the joint is 
flexed, the tibia is displaced backward and rotated outward, and there is 
marked over-riding of the femur. Bony anchylosis in this position is 
often seen. 

Symptoms. — The earliest symptoms of disease at the knee are usually 
a slight stiffness of the joint, with a disposition to flexion and slight 
lameness. At first these symptoms are noticed only occasionally ; finally 
they become constant and there is pain, which is usually referred to the 
knee. In some cases there are "starting pains" at night, although these 
are less constant and less severe than in hip-disease. Swelling is noticed 
early, as the diseased parts are so superficial. At first this is chiefly of 
the bone itself ; the condyle, usually the inner one, is enlarged and elon- 
gated, often to a marked degree, before there is any infiltration of the soft 
parts. Later there is a general fusiform swelling, involving the entire 
joint and effacing all the normal outlines. Some tenderness upon pres- 
sure over the bone affected is present quite early, and there may be atrophy 
of the muscles of the thigh and calf. The knee is flexed and slightly 
rotated outward, the position which secures the most complete relaxation 
of the joint structures. In some cases there is seen the characteristic 
swelling due to distention of the synovial membrane. Abscesses may 
form anywhere about the joint ; very frequently they burrow beneath the 
tendon of the quadriceps extensor as far as the middle of the thigh. 
Gradually the deformity increases until the leg may be flexed at a right 
angle, and rotated outward over an arc of twenty or thirty degrees. 

The course of the disease resembles that of ostitis of the hip and the 
spine. During periods of remission, pain and tenderness often subside for 
several months so completely as to lead to the supposition that the disease 
has been arrested. An exacerbation is often excited by a fall or a strain 
of the joint, or it may follow an attack of acute illness. The disease may 



TUBERCULOUS DISEASES OF THE BONES AND JOINTS. 849 

then progress rapidly and abscess after abscess form, with extensive de- 
struction of all the joint structures and the production of permanent 
deformity. 

Prognosis. — The danger to life is considerably less than in disease of 
the hip or spine. Death, however, results from the same causes — exhaus- 
tion, amyloid degeneration, and general tuberculosis or tuberculous men- 
ingitis. 

With an early diagnosis and proper treatment the disease may, in a 
considerable proportion of cases, remain limited to the bone, and the 
resulting lameness and deformity be very slight ; but otherwise a certain 
amount of lameness results from the stiffness of the joint. This may be 
due either to fibrous thickening or to bony anchylosis. Nearly all patients 
are able to walk without crutches, and if proper treatment has been carried 
out there is neither marked shortening nor deformity, although there is 
always great muscular atrophy. 

Diagnosis. — The important symptoms for diagnosis, are the gradual 
onset, the early swelling which is due to enlargement of the bone, and the 
constant lameness and deformity. The disease may be confounded with 
rheumatism, with synovitis, and even with scurvy. In all these cases the 
resemblance exists only during the period of exacerbation. A careful his- 
tory, however, will usually clear up the diagnosis. 

Treatment. — The general treatment is the same as in other forms of 
joint disease. The indications for local treatment are the same as in hip- 
disease, — viz., to immobilize the affected limb and prevent deformity. 
This is accomplished by a form of apparatus which transfers the weight 
of the body from the joint to the perinaeum, and which overcomes the 
muscular spasm which produces flexion and inward rotation of the joint. 
As in hip-disease, the results of mechanical and constitutional treatment 
are decidedly better than early operative measures; but late operations 
are indicated under the same conditions. 

Tuberculous Osteo-Myelitis. — This disease is rarely seen except in 
the short tubular bones, most frequently those of the hand and fingers. 
From this fact it is often called scrofulous or tuberculous duett// if is. It 
is described by many writers under the name of spina ventosa. CTnger* 
gives the following figures showing the frequency with which the different 
bones were affected: fingers in 43, toes in 3, metacarpus in 41, metatarsus 
in 14, radius in 2, ulna in 2, tibia in 3, jaw in 3. The first phalanx of the 
index finger is the bone which is most frequently the scat of disease. In 
the majority of cases the process is confined to a single bone, although it 
is not rare to see five or six affected. In such cases the disease is seldom 
symmetrical. The process is a chronic inflammation, beginning in the 
centre of the bone with the deposil of tuberculous material. The swelling 



* Archiv fur Kinderheilkunde, Bd. ii. 283. 
63 



850 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

which follows causes an expansion of the bone and thinning of the shaft, 
until a mere shell may remain. The later changes are, inflammation of 
the periosteum and the soft parts, the formation of abscesses and sinuses, 
necrosis, the exfoliation of sequestra, etc. The entire disease lasts from 
one to three years, and causes in most cases marked deformity. 

Tuberculous dactylitis is essentially a disease of early childhood, being 
seen most frequently during the second and third years. In a considerable 
proportion of the cases there is a history of inherited tuberculosis. It 
usually exists as the only tuberculous lesion in the body, but occasionally 
it is associated with tuberculosis of the hip, knee, ankle, or spine. 

Symptoms. — Tuberculous dactylitis usually begins as a painless enlarge- 
ment of one of the phalanges, most frequently the first one of the index 
finger. It may be two or three months before it is of sufficient size to 




Fig. 146. 



-Tuberculous dactylitis of the first phalanx of the index finger. 



attract much attention. Exceptionally the inflammation is a more active 
one, and is accompanied by both pain and tenderness. The swelling is 
quite characteristic ; it is smooth, hard, uniform, and generally spindle- 
shaped, involving the entire phalanx of the affected finger. The appear- 
ance of a severe typical case is shown in Fig. 146. Later there is discol- 
ouration of the skin, and usually there is suppuration. The abscess 
generally opens at the side of the finger, and a curdy pus is evacuated. If 
the opening is enlarged by an incision there is found a cavity partly filled 
with caseous matter, and dead bone is felt, and perhaps a loose sequestrum. 
The cavity is surrounded by a thin shell of new bone, which is formed 
from the periosteum. If no operation is done the discharge continues for 
weeks or months, other abscesses often form, and finally several small 



SYPHILITIC DISEASES OP BONE. 851 

sequestra are exfoliated, — sometimes a single large one, which is the shell 
of the diseased phalanx almost entire. 

In some cases the disease is arrested before necrosis occurs, but in the 
majority this is not so. After the wounds have all healed the finger 
remains shortened, deformed, and often useless. In some cases the disor- 
ganization is so extensive that amputation is necessary. 

Diagnosis. — The recognition of dactylitis is usually easy, but as symp- 
toms identical in almost every particular may be seen in a syphilitic in- 
flammation, it is often difficult to tell with which of the two forms one 
has to deal. The tuberculous form is very much more frequent ; it may 
occur in a patient with tuberculous antecedents, or it may be associated 
with other tuberculous lesions. Syphilitic cases are distinguished by the 
fact that the lesion is more frequently multiple, that it is often symmetri- 
cal, and that other manifestations of syphilis are generally present. It is 
affected by anti-syphilitic remedies, which is not the case in the tubercu- 
lous variety. 

Treatment, — Painting with iodine and like measures are useless. The 
diseased part should be kept at rest, — if a finger, by the ajiplication of a 
splint. Every means should be taken to build up the patient's general 
health, as this is the most effective way to influence the local process. The 
general verdict of surgeons is against early excision as a means of arresting 
the disease. Abscesses should be opened early and freely, all diseased 
bone removed, the finger kept in proper position, and the wound treated 
according to general surgical principles. Under almost any treatment the 
disease is a protracted one, and rarely lasts less than a year. 

THE SYPHILITIC DISEASES OP BONE. 

The bone lesions of hereditary syphilis are not infrequent, but were 
long unrecognised, and have only within comparatively recent times been 
fully understood.* They may be divided into two groups,— those occur- 
ring with the early symptoms, and those which belong to the late; manifes- 
tations of the disease. 

Acute Epiphysitis. — This is the most frequent variety of bone dis- 
ease in early hereditary syphilis. It may begin even in intra-uterine lite, 
and it forms one of the most characteristic lesions of the disease. To some 
degree it is almost invariably present in syphilitic foetuses and in syphilitic 
infants who are still-born. 

In the early stage, there is an increase in the cartilage cells and delayed 
ossification. Later, a line of softening forms at the epiphyseal junction, 
which may cause loosening of the cartilages and ultimately complete 
separation of the epiphysis from the shaft, by the formation of granula- 

*See Taylor, Bone Syphilis in Children, New York, is;:*: also (I. Wegner, Vir- 
chow's Archives, Bd. 1, Heft 3. 



852 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

tiou tissue between them. In cases receiving proper treatment, recovery 
may take place with good union, perfect function, and without any de- 
formity. In other cases degenerative changes continue, and infection 
with pyogenic germs may be added. The periosteum and the soft 
parts in the neighbourhood are now involved, with the formation of 
external abscesses ; or the disease extends to the medullary cavity, giving 
rise to acute osteo-myelitis, which may lead to necrosis; or the contiguous 
joint may be invaded, causing an acute suppurative arthritis (page 835). 
This last result is more likely to occur where the epiphysis joins the shaft 
within the joint cavity. The large joints are usually affected, and the 







Fig. 147.— Syphilitic bone disease in a boy four years old. The lower end of the radius of both 
arras is enlarged as a result of former epiphysitis ; there are sinuses leading to dead bone 
over the metacarpal bone of the right thumb, and over the upper extremity of the left ulna. 
The last two are recent lesions. 

lesions are frequently symmetrical. Acute suppurative arthritis may oc- 
cur independently of changes at the epiphysis ; but even when these are 
seen in syphilitic infants they are to be regarded as of pyaemic rather 
than of syphilitic origin. Secondary to the changes at the epiphysis, there 
are periostitis and inflammation of the soft parts. Periostitis of the shaft 
is rare in early infancy, 

The bones most frequently the seat of acute epiphysitis are the 
humerus, radius and ulna, although any of the long bones may be 
affected. 

Symptoms. — The early symptoms are usually quite acute, and appear 
during the first six weeks of life; they may precede any other mani- 
festations of syphilis. In some cases there is first noticed an inability on 






SYPHILITIC DISEASES OF BONE. 853 

the part of the child to move the limb, which may easily be mistaken for 
paralysis. It is, in fact, often described as " syphilitic pseudo-paralysis." 
The limb lies perfectly motionless, and any attempt at passive movement 
causes evident pain. There is tenderness on pressure and soon swelling is 
seen, both being most marked at the epiphyseal line. If the bone affected 
is superficially situated, as the lower epiphysis of the humerus, radius, or 
tibia, swelling is very apparent, while it may be scarcely perceptible at the 
upper epiphysis of the humerus. The swelling is usually cylindrical and 
moderate in degree, being limited to the extremity of the bone. In the 
more severe cases it may involve a great part of the limb. Abscess may 
form and separation of the epiphysis take place, so that crepitation may 
be obtained by moving the limb. Separation of the epiphysis not infre- 
quently occurs even when there has been no suppuration. 

In the milder cases, or those which have been subjected to active 
treatment, both the swelling and the tenderness subside rapidly without 
suppuration ; and even though the epiphysis has separated from the shaft, 
it speedily unites. Where pseudo-paralysis has been the chief symptom, 
very rapid improvement occurs under treatment, and usually complete 
recovery of function in two or three weeks. If the disease extends to the 
joint, or if osteo-myelitis develops, the case is almost certainly fatal. 

Diagnosis. — This is usually easy, from the age of the patient — gener- 
ally under three months — the early prominence of pain and apparent loss 
of power, with the later appearance of swelling and signs of inflamma- 
tion at the epiphyseal junction. In all these respects the disease closely 
resembles scurvy ; but the latter is rare before the eighth or tenth month, 
there is usually a history of the long-continued use of some proprietary 
infant food, and it is cured by dietetic treatment alone. 

The apparent loss of power may lead to the diagnosis of birth palsy, 
especially of the upper-arm type (page 110). The presence of acute pain 
and tenderness, the absence of the characteristic deformity, and the prom pi 
recovery under constitutional treatment, usually make the distinction be- 
tween the two conditions an easy one. 

Treatment. — This is the same as in all early syphilitic manifestations, 
for which see the article on Syphilis. Locally, the part requires in the 
early stage only protection and rest. Should suppuration occur in the 
neighbouring joint, or should osteo-myelitis develop, these conditions 
should be treated surgically as they are when due to other causes. 

Chronic Osteo-Periostitis.— This is the usual form of bone disease 
which is seen in late hereditary syphilis, and it is one of the most frequent 
and most characteristic lesions of that stage of the disease. Occurring 
in adults, this would be classed as a tertiary symptom. Chronic syphilitic 
osteo-periostitis is rarely seen before the third year, and most of the cases 
occur between the fifth and fourteenth years. The mosl frequenl seal of 
disease is the tibia, and next to this the bones of the forearm and the 



854 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

cranium. The following is the frequency with which the different bones 
were affected in the series of cases reported by Fournier : * tibia in 91 
cases, ulna in 22, radius in 15, cranium in 16, humerus in 12, all others in 
37. The process may result either in a diffuse or a localized hyperplasia 
of bone or in necrosis. 

The typical changes are seen in the tibia. The shaft of the bone is 




Fig. 148. — Syphilitic disease of the tibia, showing the sabre-like deformity, in a boy 

nine years old. 

principally or solely affected. There is often produced a very characteristic 
deformity, consisting of a forward curve of the anterior border of the 
tibia, which has been compared to a sabre blade (Fig. 148). In some 
cases the bone is bent inward at its lower third, resembling somewhat a 
rachitic curvature (Fig. 149). Sometimes the entire shaft of the bone is 
affected, and it may be enlarged to nearly twice its normal dimensions. 



* Syphilis Hereditaire Tardive, Paris, 1886. 



SYPHILITIC DISEASES OF BONE. 355 

At other times the swelling is chiefly near the epiphysis, where large 
bosses may form of sufficient size to interfere with the functions of the 
joint. Instead of affecting the bone uniformly, the disease often affects 
only certain parts, leading to the formation of large nodes which are more 
likely to be followed by necrosis than are the other lesions. In most of 
the cases the process is purely a hyperplastic one, leaving the bone per- 
manently enlarged. Less frequently, there occur gummatous deposits 




Fig. 149.— Syphilitic disease of both tibiae. r I he left shows a general enlargement o the bone, 
the characteristic curve of its anterior border, with ulcere due to oeerana. I he enlarge- 
ment of the right tibia is less marked, and there is a pseii.lo raeli.lie eurve at its lower 
third. Cicatrices near the knee mark the site of former ulcere. I After Fournier.) 

in or beneath the periosteum, which may soften, suppurate, and Lead to 
superficial necrosis, with the formation of sinuses that remain open until 
the sequestrum is exfoliated (Fig. 150). Syphilitic deposits sometime* 
take place in the interior of the bones, generally near the articular ends; 
these may soften and break down with abscesses, sinuses, etc., very much 
after the manner of a tuberculous inflammation ( Pig. L47). 

The lesions of the other long bones are essentially the same as of the 
tibia. They are nearly always symmetrical and often multiple. In a case 
recently under observation in a boy of four years, flic disease involved 
both tibiae, both radii, the right ulna, the left metatarsus, and tin- meta- 
carpal bone of the left thumb. The course of syphilitic oeteo-periostitifl 



856 



DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 



f 



is very chronic, and some permanent deformity is the rule, unless cases 
come very early under treatment. 

When affecting the bones of the cranium the disease usually takes the 
form of a gummatous periostitis, which leads to the formation of large 
nodes. These may remain as permanent deformities, or they may break 
down and suppurate, with necrosis of one or both tables of the skull. 

This may be followed by inflammation 
of the dura, the pia, and even of the 
brain itself. 

Symptoms. — When the long bones 
are affected, the symptoms are pain, 
tenderness and deformity. These come 
on very gradually, and often the de- 
formity is noticed before either pain or 
tenderness is sufficiently marked to at- 
tract attention. The pain is regularly 
worse at night, and often felt only at 
that time ; it may be mild and occa- 
sional, or so severe as virtually to pre- 
vent sleep. There is tenderness on 
pressure over the bones affected, the 
acuteness of which will depend upon 
the activity of the process. When sup- 
puration occurs, it comes very slowly, 
and never with symptoms of acute in- 
flammation. Sinuses usually continue 
to discharge until a sequestrum is ex- 
foliated. The course of the disease is 
very tedious, and the whole duration is 
usually several years. 

When the cranium is affected, there 
are seen the irregular nodes, especially 
upon the frontal and parietal bones. They are from one to two inches 
in diameter, and project from one eighth to one fourth of an inch above 
the general outline of the skull. There may be pain, tenderness, soften- 
ing, suppuration, and necrosis, as in the long bones. 

Diagnosis. — It is so' very rare that disease of the bones of the cranium 
is due in childhood to any other cause than syphilis, that this disease may 
always be assumed to exist if traumatism can be excluded. The bosses 
upon the cranium in rickets (page 226) are always large, smooth, and 
regular in position, and belong to infancy. 

Syphilitic disease of the long bones is recognised by the nocturnal 
pain, the tenderness and peculiar deformity, and by the association of 
other late manifestations of syphilis, — i. e., the peculiar notched teeth, 




^\ 



M^$&&« 



Fig. 150. — Syphilitic necrosis of the tibia, 
showing moderate enlargement of the 
bone and a sinus. ( From the same pa- 
tient as Fig. 147.) 



SYPHILITIC DISEASES OF BONE. 857 

the interstitial keratitis, the enlarged epitrochlear glands, etc. Tuber- 
culous disease generally affects the articular ends of the bones; syphilis 
nearly always the shaft. The diffuse hyperplasia of the tibia and the 
sabre-like deformity of its anterior border, are rarely if ever due to any 
other cause than syphilis. 

The deformities of the long bones have in some cases a certain resem- 
blance to those due to rickets, but on close examination there are seen 
striking differences. The epiphyseal enlargement at the wrist in rickets 
affects both bones (Plate V, page 222) ; in syphilis it is usually of one 
bone only (Fig. 147). The differences between rachitic curvatures of the 
tibia and the deformities from syphilis may be readily seen by comparing 
Figs. 38, 39, and 40 (pages 227 and 228) with Fig. 149. 











Fig. 151. — Multiple syphilitic dactylitis, in a child two years old. The disease affects the lirst 
phalanges ofhoth thumbs, both little fingers, and the index finger of the left hand. 

Treatment. — The constitutional treatment of these lesions is the same 
as that of the other late manifestations of syphilis, — mercury and the 
iodide of potassium; for details, see the chapter on Syphilis. Surgical 
treatment is required in cases which terminate in necrosis, whether of the 
cranium or the extremities. They are to be managed like the same con- 
ditions in adults. 

Syphilitic Dactylitis. — This belongs to a somewhat earlier period 
of syphilis than the disease just described, and is usually Been in children 
under five years old. It is not a frequent manifestation of syphilis, and 
as compared with tuberculous dactylitis it is rare. It was lirst full) de- 
scribed by Taylor (New York). The symptoms closely resemble the tuber- 
culous form. It may begin as a periostitis but more frequently as an 
osteo-myelitis. Like the tuberculous form it usually goes on to suppura- 
tion and necrosis. According to Taylor, dactylitis is more often Bingle 
than multiple, but in my own cases Beveral phalanges have generally been 



§58 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

involved, and the lesions have often been symmetrical (Fig. 151). In one 
case, the first phalanx of every finger of both hands was affected. This oc- 
curred in a child nine months old who was under observation for over two 
years, and who presented during this period almost every lesion of he- 
reditary syphilis. 

The symptoms and course of syphilitic dactylitis are essentially the 
same as in the tuberculous form. The differential diagnosis is considered 
with the latter disease (page 851). The prognosis is much the same in 
the two varieties, with the exception that in the early stage the syphilitic 
cases may often be arrested by constitutional treatment. This is the same 
as in other late lesions of syphilis. The same local treatment should be 
employed as in the tuberculous cases. 



CHAPTER V. 

DISEASES OF THE SKIN. 

The skin at birth is covered with a whitish sebaceous secretion, the 
vernix caseosa. The skin itself is of a deep purplish colour, which changes 
to a bright red over the face and trunk in a few minutes, with the estab- 
lishment of normal respiration, and in a few hours the whole body has 
the same tint. This excessive redness slowly fades during the first month, 
at the end of which time the skin has assumed the pale pink of infancy. 
On the third or fourth day there are usually seen the first signs of icterus ; 
this generally fades by the end of the second week. 

The epidermis which is present at birth soon loosens and is thrown 
off. This normal desquamation usually begins upon the fourth or fifth 
day, and is completed in ten days or two weeks. If the skin is frequently 
oiled and properly bathed, desquamation is scarcely noticeable unless a 
close examination is made. In some infants, especially those who are deli- 
cate and cachectic, it is very much more marked, and closely resembles 
that seen in scarlet fever. Eitter has described an exfoliative dermatitis 
of the newly-born, appearing generally during the second and third weeks, 
a condition which is regarded by Kaposi as simply an exaggeration of 
normal physiological desquamation. This process may be mistaken for 
that due to hereditary syphilis ; the latter, however, is rarely general, ap- 
pears later, and is much more prolonged. 

Perspiration is rarely present before the end of the fourth month, and 
is then seen only upon the forehead. In healthy infants it is scarcely 
noticeable during the first year. Copious perspiration is most frequently 
a symptom of rickets ; less marked perspiration may occur with any gen- 
eral weakness or during acute illness. 



CONGENITAL ICHTHYOSIS. 



859 



CONGENITAL ICHTHYOSIS. 

Congenital, or more properly foetal, ichthyosis, sometimes known also 
as diffuse keratoma, is a rare disease, characterized by the formation, usu- 
ally all over the body, of a thick, horny epidermis resembling parchment. 
This is divided by fissures or shallow furrows into irregular patches; 
sometimes these are two or three inches wide, at others as small as a pin's 
head. The disease begins in the early months of foetal life, and is an 
abnormality in the development of the skin, there being an excessive pro- 
liferation of the layers of the epidermis. 

Symptoms. — In the gravest form of the disease the child often lives but 




Fig. 152.— Congenital ichthyosis in a child ten months old. The large scaly patches are wi 

shown on the lower part of the right chest and abdomen, and the constricting bands upon 
the legs. (From a photograph by Dr. Cabot.) 

a few hours, and rarely more than a week. The openings of the nostrils 
and the ears may be occluded by the excessive production of epithelial cells. 
The eyes are in a condition of ectropion, and there are often deformities 
of the mouth and other orifices due to the contractions of the skin. The 
nails and hair are usually imperfectly developed. The body seems in- 
cased in a hard, horny covering, and looks as if it had been Tarnished or 
covered with collodion. The skin cracks or splits and the edges cnrl tip, 
an appearance which lias been aptly compared to the skin of a boiled 
potato. 

In the milder form, the duration of life is indefinite, depending upon 



860 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

the degree of development of the disease ; but even in such#cases there 
are frequently seen the deformities at the orifices of the body, and there 
may also be a continued exfoliation of the epidermis in large irregular 
patches. After this has separated, the skin beneath appears red and moist, 
but gradually becomes dry, hard, and shining, slowly contracting until it 
splits in various directions. In a case recently under observation in the 
Babies' Hospital,* a picture of which is shown in the accompanying illus- 
tration (Fig. 152), it was stated by the mother that during the first ten 
months of life complete exfoliation of the skin had occurred in the course 
of every two or three months. 

The outlook is bad in all cases ; in most of the severe forms death 
occurs in infancy, but in some of the milder ones, life may be prolonged 
throughout childhood. The " alligator boy " of the Dime Museum is an 
example of this class. 

Treatment. — The indications are to keep the skin moist and soft by 
the use of oils, continuous baths, etc., and to prevent infection by perfect 
cleanliness. Although a certain amount of improvement usually follows 
these measures, a cure is not to be expected. 



MILIARIA. 

The term miliaria is applied to an obstruction of the sweat glands, 
which may occur either with or without inflammation. The non-inflam- 
matory form is known as sudamina, the inflammatory forms as miliaria 
rubra, miliaria vesiculosa, and miliaria papulosa. 

Sudamina. — In this form there is no inflammation. The sweat ducts, 
according to Crocker, are blocked by an accumulation of epithelial cells 
while no perspiration is going on ; and when the process is restored the 
fluid, being unable to escape, accumulates in the form of tiny vesicles. 
These appear like small pearly bodies very closely set, and disappear in 
the course of a few days by absorption. Fresh crops may appear from time 
to time. Sudamina may be seen in any of the continued fevers or ex- 
hausting diseases. It requires no treatment. 

Miliaria Rubra. — This condition, also known as red gum, strophulus, 
etc., is a sweat rash, usually seen in young infants as the result of excess- 
ive clothing. It is most frequently observed upon the cheeks and neck, 
often upon the side of the face upon which the infant sleeps, or the side 
held against the mother's body while nursing, if this is done upon only 
one breast. The eruption consists of scattered red papules, sometimes 
with tiny vesicles. Miliaria rubra is an inflammation about the sweat 

* This case has been fully reported by Cabot, New York Medical Record, July 6, 
1895. For fuller description of the disease, see Ballantyne, Diseases of the Foetus, vol. 
ii, 1895 ; also Archives of Paediatrics, April and June, 1894. 



MILIARIA. 861 

glands, the result of which is a retention of their secretion. There is 
generally little or no itching. The treatment consists in the removal of 
the cause, and the application of some absorbent powder, such as boric 
acid and starch. 

Miliaria Papulosa (Lichen Tropicus, Prickly Heat, etc.).— This is the 
most common and most important variety of miliaria. There is in this 
disease an obstruction of the sweat glands by inflammatory products. The 
lesion consists in the formation of bright-red papules, which are very 
closely set, the summits of some of them being surmounted by tiny vesi- 
cles, and here and there in severe cases even small pustules may be seen. 
If not interfered with by scratching, the vesicles dry up without rupture, 
and are followed by a slight desquamation. Where there is much scratch- 
ing, an eczematous condition may result. Miliaria papulosa comes out 
with great rapidity, especially upon the neck, forehead, back, and chest. 
It is accompanied by an almost intolerable itching and stinging sensa- 
tion. Over other parts of the body profuse perspiration occurs. The 
disease is produced by very hot weather and excessive clothing. Although 
the duration of a single attack is but two or three days, in susceptible 
patients it may keep recurring for weeks, being exceedingly intractable. 
Where there is much scratching the resulting eczema is very troublesome. 
It is not infrequently followed by furunculosis. 

The diagnosis of miliaria rubra and miliaria papulosa is usually easy. 
They are distinguished from eczema by the suddenness with which they 
appear, by the associated sweating of other parts of the body, by the tran- 
sitory character of the eruption, and by the fact that the rash never occurs 
in circumscribed patches. Prickly heat sometimes resembles the rash of 
scarlet fever, but the fact that the tiny papules are in some places crowned 
by vesicles and that constitutional symptoms are absent, usually make the 
distinction an easy one. 

Treatment. — Prickly heat is to be prevented by light clothing, fre- 
quent bathing, and the plentiful use of a good toilet powder, such as boric 
acid and starch. During an attack, the bowels should be freelj opened by 
calomel or a saline, and secretion of the kidneys stimulated by the use of 
nitrate of potassium or the sweet spirits of nitre. The skin should be 
protected against the irritation of flannel undergarments by the interposi- 
tion of silk or linen. When the inflammation is at its height, relief is 
obtained by the application of a calamine and zinc lotion (page 869), or by 
a dilute solution of the acetate of lead; carbolic acid may be added to 
either, where the itching is intense. In some cases powders are preferable 
to lotions. One of the best is the stearate or the oxide of zinc, twelve 
parts; bismuth, three parts ; powdered camphor, one part; or equal parts 
of starch and boric acid may be used, or simply rice Hour. All of these 
must be very freely applied. The diet, should he light and fluid, and if 
milk is the food it should be considerably dilated. 



862 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 



SEBORRHEA. 

Seborrhoea is considered by dermatologists generally, as a functional 
disease of the sebaceous glands ; although Unna regards all such cases as 
inflammatory, and classes them as seborrheic eczema, which is of para- 
sitic origin (page 865). The disease may affect almost any part of the 
body, and children of any age, but the most frequent form is that which 
is seen upon the scalp in young infants. This is the most important 
variety, and the only one which will be here considered. 

Seborrhoea of the scalp is characterized by the formation upon the 
vertex, of dirty-yellow crusts, which are soft, greasy, and friable. They 
are composed of epithelial cells, fat-globules, and granular masses, to which 
is always added dirt. In neglected cases the hairy scalp is nearly covered 
by a dense crust, which may be as thick as heavy pasteboard. If the 
crusts are removed the underlying scalp may be found perfectly healthy, 
but more frequently, in cases of long standing, it is eczematous. The 
eczema is set up by the decomposition of the exudation, or by the efforts 
to remove the crusts by such means as the fine-toothed comb, commonly 
employed in domestic practice. There is little tendency to spontaneous 
improvement or recovery, and the condition often lasts for months. Every 
seborrhoea should be treated, for when neglected it furnishes a favourable 
soil for the development of eczema. 

Treatment. — Only local measures are required. The crusts are first to 
be softened with oil, and then removed by washing thoroughly with warm 
water and soap, after which an ointment of resorcin (resorcin, gr. x ; ungt. 
aquae rosae, § j) or sulphur (precipitated sulphur, 3 j ; lanoline, § j) 
should be applied. The oil and soap and water are repeated every few days, 
or as often as the crusts form. In the meantime the scalp is kept cov- 
ered with the ointment. 

ECZEMA. 

Eczema may be defined as a catarrhal inflammation of the skin. It 
is the most frequent and altogether the most important disease of the skin 
in early life. The scope of the present work permits only a discussion of 
such features and varieties as are peculiar to infants and young children. 
The eczema of older children does not differ in any essential points from 
that of adults. 

Etiology. — The conditions in infancy which predispose to eczema are, 
first, that the skin is extremely delicate, and hence more easily affected by 
external irritants and micro-organisms ; secondly, its more intense glandu- 
lar activity. While all children are susceptible, there are certain ones 
in whom the susceptibility is very marked, and in them the slightest 
amount of external irritation, or the most trivial disturbance of diges- 
tion may produce a severe eruption. It was formerly the fashion to class 



ECZEMA. 863 

eczema of the face and scalp among the manifestations of infantile 
" scrofula." It is true that certain infants are prone to eczema, as others 
are to catarrhal processes of the mucous membranes, but no more can 
be positively affirmed. We certainly can not connect eczema with any 
single diathetic condition ; but it is much more often seen in children 
with gouty antecedents than in others ; or to state it differently, the most 
frequent manifestation of gout during infancy is the tendency to eczema. 
Children of rheumatic families are also prone to the disease. Eczema of 
the face is common in fat, healthy-looking infants, and is seen both in 
those who are nursing and in those who are artificially fed. It also occurs 
in flabby, poorly nourished children, but rarely in those suffering from 
marasmus. 

The exciting causes of eczema may be external or internal. Of the 
former the most important are heat, cold dry air, and winds — as in the 
familiar chapping of the face — the use of hard water or of strong soaps 
in bathing. The disease may be due to the irritation of clothing, to want 
of cleanliness, or to irritating discharges from mucous surfaces, as in the 
eczema of the upper lip, thighs, or buttocks. It accompanies most of the 
parasitic skin diseases, particularly pediculosis, scabies, and ring-worm. It 
is probable that in many forms of eczema micro-organisms play an impor- 
tant part; even though they may not have been the primary factor in 
causing the disease, they may suffice to continue the inflammatory process. 

The internal causes of eczema are chiefly associated with deficient 
elimination from the kidneys and bowels, aud digestive disturbances. It 
often accompanies chronic constipation where there is intestinal torpor 
and the white stools of deficient biliary secretion ; and it is seen where the 
urine is scanty and concentrated because children partake too largely of 
solid food. The latter is true both in the first and second years. 

Eczema may be produced by any form of digestive disturbance, hut it 
is especially frequent in the intestinal indigestion which results from 
overfeeding, or the too early or excessive use of farinaceous food, or from 
breast milk in which the percentage of fat is very hi gh. From personal 
experience in the post-mortem room, I can confirm the observation of 
Bohn regarding the frequency with which fatty liver occurs in very fat 
infants. Enlargement of the liver may sometimes be made oul during life. 
It is highly probable that the interference with the hepatic functions which 
accompanies these fatty changes has much to do with the production of 
eczema in such subjects. In children U><\ upon cow's milk the excessive 
fat may be the cause, or it may be due to excessive proteids. Of farina- 
ceous articles, the two which are most of ten to be blamed arc potato and 
oatmeal. Although eczematous patients usually appear to be well nour- 
ished, it is rare that some symptoms of indigestion are nol present 

Eczema is often due to some form of reflex irritation. Such are the 
cases which accompany dentition, and the rare ones due to genital irrita- 



864 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

tion. By many writers the eczema caused by disorders of the stomach or 
intestines is regarded as reflex. The stronger the predisposition, the more 
trivial is the reflex irritation which will induce an eruption. 

Simple Chronic Eczema — Eczema Rubrum. — This is the most frequent 
form of eczema occurring in infants and young children, and is usually 
seen upon the face. It affects by preference the cheeks, forehead, and 
scalp, not infrequently the ears and neck, and may occur upon any part 
of the body. Upon the trunk and extremities the eruption is usually in 
patches, but in rare cases may cover nearly the entire body. The disease 
generally begins upon the cheeks with the formation of small red papules ; 
later these coalesce, and there is a moist, red surface exuding serum or 
sero-pus. The secretion dries and forms thick, gummy crusts, which may 
be so hard as to form a mask for the face. From the scratching caused 
by the almost intolerable itching, the surface bleeds freely, and the dried 
blood gives to the crusts a dirty-brown colour and adds to the distressing 
appearance. The skin is often much swollen. After the removal of the 
crusts there is seen, in acute cases, a red, inflamed, granular surface, dis- 
charging pus or serum and bleeding readily. When the process is less 
active, there are redness, thickening, induration, and scaliness of the skin, 
and marked itching. In the same case these stages may alternate, exacer- 
bations occurring whenever the exciting cause is particularly active. 
From the cheeks the disease spreads to the forehead, ears, and scalp, and 
here similar lesions are seen. Upon the trunk and extremities thick crusts 
rarely form, but the skin is red, thick, and scaly. The parts most often 
affected are the forearms, chest, elbows, knees, abdomen, and back ; occa- 
sionally the eruption is general. 

Swelling of the lymph nodes in the neighbourhood of the eruption is a 
constant feature of eczema of the face and scalp ; these may reach the 
size of a chestnut or walnut, and occasionally they suppurate. Intense 
itching is a characteristic feature of all cases of eczema of the face or 
scalp. It causes restlessness and loss of sleep, and usually it is only in 
this way that the disease affects the general health of the patient ; but in 
most cases the health remains good. With eczema of the occipital region 
of the scalp, pediculosis is usually associated. 

Eczema of the face is very chronic, easily improved, but cured only 
with great difficulty. There is a strong tendency to relapses, brought on 
by neglect of local treatment or by any digestive disturbance. 

The predisposition to eczema often ceases with the second year ; those 
who have suffered from it almost constantly during infancy may be free 
from it during the remainder of childhood. This is in part to be ex- 
plained by the loss of fat in consequence of more active exercise and a 
diet which is more largely nitrogenous. Where the disease continues 
through the third and fourth years, the associated infantile condition- — 
obesity — is not infrequently present. 



ECZEMA. 865 

Seborrheic Eczema. — This form of eczema has been brought into 
prominence by the writings of Unna, according to whom not only are all 
the cases usually classed as seborrhoea to be regarded as eczematous, but 
also many others classed as ordinary eczema. Instead of seborrheic 
eczema being a form of disease in which the fat-producing glands are 
involved in the inflammatory process, Unna believes it to be parasitic and 
due to a certain " mulberry coccus " which he has described. Although his 
investigations have not yet been corroborated, there are many arguments 
in favour of the pathology which he has advanced for this disease. Elliot, 
who accepts Unna's views, defines seborrheic eczema as follows : " An 
inflammatory disease of the skin, catarrhal in "nature, due to micro-organ- 
isms — a parasitic dermatitis — characterized by its primary seat being upon 
the scalp, whence it tends to spread downward, involving by preference 
the middle portion of the face, the sternal and interscapular spaces, axilla, 
and inguinal regions, but may affect any part of the body." * The lesions 
upon the scalp may be of the nature of a dry seborrhoea with yellow 
greasy crusts, or like pityriasis. Upon the body, the eruption is scaly, with 
red macules or papules, or it may be accompanied by greasy crusts like 
those seen upon the scalp. The skin is not usually thickened and the 
lesions are not elevated. Itching in most cases is only moderate, and it 
may be absent; but in some of the most severe cases it is marked and ac- 
companied by tingling. An extensive weeping surface is never seen. All 
the crusts are soft and contain fatty matter. The lesions are not deep, 
and the disease frequently shifts from one part of the body to another, 
often coming out very rapidly. In most cases the patches are rather 
sharply defined and have rounded borders. 

Pustular Eczema of the Scalp.— This condition, often called "simple 
impetigo," is less frequently seen in infants than in children from two to 
five years old. There are usually present from half a dozen to fifty 
greenish-yellow crusts, matting the hair, usually discrete, but sometimes 
coalescing to form a mask over half the scalp. There is very little itch- 
ing, in some cases none at all. The lymph glands are invariably enlarged. 
There is frequently continued auto-infection, and in this way the dis< ase 
may be prolonged indefinitely. It is possible, too, that in feet ion may 
spread to other children. 

Intertrigo. — This term is rather indiscriminately applied to any erup- 
tion which develops upon two moist surfaces, which are in contact It 
is often regarded as a form of eczema, although, as Elliol has well 
pointed out, there are seen several processes which are quite distinct 
from one another. The most frequent is a simple erythema; in other 
cases there is an eczema resulting from traumatism or the decomposition 



* Morrow's System of Genito-Urinary Diseases, Syphilology, and Dermatology, 

vol. iii, D. Appleton & Co., 1895. 
64 



866 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

of secretions, or a seborrhoeic inflammation. Intertrigo is seen in the 
folds of the groin, between the scrotum and the thighs, between the but- 
tocks, about the anus, in the axillae, in the neck, or behind the ears. Its 
essential causes are moisture, friction, want of cleanliness, and sometimes 
infection. The disease is generally seen in its worst form about the 
thighs, genitals, and buttocks ; it sometimes covers the sacrum and ex- 
tends down to the middle of the thighs. There is an intense uniform 
redness, and in some cases the epidermis is denuded over large areas, and 
the surface is moist. There is no thick crusting and little or no itching. 
Intertrigo is usually easy to control except in very poorly nourished or 
marantic children, among whom it is especially frequent. 

Diagnosis of Eczema. — This is usually quite an easy matter. In the 
majority of cases, the disease affects the face or the scalp, and its appear- 
ances are typical. Eczema of the body or extremities may be confounded 
with scabies or syphilis, and occasionally with other forms of skin disease. 
Scabies resembles eczema in its intense itching and multiform lesions; 
but in the former, one may often find evidences of its presence in other 
members of the family ; the parts most frequently affected are the flexures 
of the wrists, the elbows, the skin between the fingers, the margins of the 
axillae, the lower part of the abdomen and back, and, in boys, the penis ; 
and by careful examination with a lens some of the characteristic burrows 
are certain to be discovered. 

Syphilis is likely to be confounded with papular eczema of the but- 
tocks. The latter affects the parts near the anus, and the irritation may 
lead to the development of spots closely resembling mucous patches. The 
local appearances may at times be indistinguishable from syphilis, and the 
diagnosis is to be made only by the other symptoms present. In syphilis 
the characteristic eruption is seen usually upon the face, hands, legs, and 
sometimes the palms and soles ; there is no itching and very little evi- 
dence of inflammation ; the eruption is dark-coloured, and occurs as small 
circumscribed spots; there are usually present other symptoms, such as 
the coryza, the syphilitic cachexia, and enlargement of the spleen. 

The diagnosis from pediculosis and ringworm of the scalp, rarely pre- 
sents any difficulties. 

Prognosis. — All cases of chronic eczema are tedious. There is only a 
slight tendency to spontaneous improvement, and very little to spontane- 
ous recovery during infancy. In a given case, the prognosis depends upon 
the duration of the disease, its severity, and very much upon the co-opera- 
tion of the mother or nurse. The results obtained depend not only 
upon the particular line of treatment adopted, but upon how well it is car- 
ried out. Usually it must be continued for several months. Eczema of 
the face is especially intractable when occurring in children suffering from 
chronic indigestion and constipation, for, unless these conditions can be 
controlled by diet and general management, local applications give but 



ECZEMA. 867 

temporary relief. Intertrigo is in most cases easily cured, unless the pa- 
tient is suffering from marasmus. 

Treatment. — It is never dangerous to cure an eczema, and always de- 
sirable to do so, in spite of the strong prejudice to the contrary, which 
still exists in the minds of the laity and in some members of the medical 
profession. To treat eczema successfully there is required a careful study 
of the exciting cause, for, although improvement often results from the 
use of local measures alone, yet in the great majority of cases this is only 
temporary. A permanent cure is brought about only by the removal of 
the cause. The physician must first endeavour to decide whether the 
eczema is due to some external or internal cause, or to both. External 
causes are for the most part easily discovered by carefully questioning the 
mother and observing how the child is cared for. Internal causes, as 
before stated, usually relate to the digestive tract or to functional disturb- 
ances of the kidneys. 

Diet. — A thorough investigation into the food is necessary, not only as 
to its character, but as to quantity and preparation, the manner and fre- 
quency of feeding, etc. If the patient is a nursing infant, an examina- 
tion of the nurse's milk is indispensable to intelligent treatment. If the 
child is very fat and well nourished, it is generally the case that the fat of 
the milk is too high and must be reduced according to the rules given else- 
where (page 164), the most important thing being to exclude from the 
nurse's diet malt liquors and alcohol in all forms, and reduce the amount 
of meat. In a smaller number of cases the trouble is with the proteids of 
the milk ; there will then be other signs of indigestion, such as colic, the 
appearance of curds in the stools, etc. The amount of food should be 
reduced by lengthening the period between the nursings, and shortening 
the time which the child is allowed to remain at the breast at one nurs- 
ing. Plain water, or better, some alkaline water, should be given freely 
between the nursings. In children fed upon cow's milk, the trouble is 
probably more often with the proteids than with the fat. The physician 
should try the effect, first of giving a milk which is low in proteids and 
moderately high in fat (e. g., formula iii or iv, page 1 75 i afterwards, one in 
which both fat and proteids are low (e. g., formula xv or xvi, page L76). 
These and other changes are to be made in the manner described in the 
chapter on Infant Feeding (pages 175-182). During the latter part of the 
first and the entire second year, the usual error is that of overfeeding 
with in most cases an excessive use of solid food, especially farinaceous 
articles. The diet should then be much reduced, and the amount of fari- 
naceous food restricted, potatoes and oatmeal being absolutely prohibited 
The diet which suits most children best is one composed of milk, beef 
juice, broth, fruit, eggs, and a little red meat, with the addition in s 
cases of rice, wheat, or barley. In severe and obstinate cases, however, 
all cereals and even meat are best omitted during the active Btage of the 



868 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

disease. The form of indigestion which exists is to be managed according 
to the special indications in each case. 

The diet of older children needs to be watched no less closely than 
that of infants. The general rules laid down elsewhere for feeding after 
the second year (pages 188-190) should be observed. The great majority 
of cases do best upon a diet which is largely fluid, and composed princi- 
pally of milk or some of its substitutes, — kumyss or matzoon. 

Elimination by the kidneys should be stimulated by the very free use of 
water, to which it is well to add — especially in cases with a gouty tendency 
— the citrate,* or acetate of potassium, from ten to twenty grains daily. 

Attention to the condition of the bowels is of the greatest importance. 
To overcome the tendency to constipation is in many cases to cure the 
eczema. Suggestions under this head will be found in the chapter on 
Chronic Constipation (page 374). Special importance is to be attached 
to the occasional use of a purge of calomel, one half to one grain being 
given every third or fourth night. The best effects from this are seen in 
over-fed children. It has a favourable effect upon the kidneys as well as 
upon the bowels. The bowels must not only be opened, they must be kept 
freely open by the daily use, if necessary, of some of the milder laxatives, 
such as phosphate of sodium, rhubarb, or cascara. Sometimes nothing 
acts so well as castor oil, which may be given in from half a teaspoonful 
to teaspoonful doses every night for two or three weeks at a time. It 
should be administered in emulsion. 

When the disease occurs in flabby, anaemic, or poorly-nourished chil- 
dren, iron and bitter tonics are required, and occasionally alcohol and cod- 
liver oil. In other words, the child's general condition should be treated 
just as if no eczema existed. Theoretically, arsenic is indicated when the 
disease is in a chronic stage with dry, scaly eruption, but its effect is often 
disappointing in infancy. It is in no sense a specific remedy. 

The general management of cases is important. The skin must be 
carefully protected by an ointment whenever the child is in the open air ; 
if the weather is very cold, or there are high winds, children with active 
eczema should not go out, but take the fresh air indoors. Never should 
an eczematous surface be washed with plain water, and much less with 
castile soap and water, so frequently employed by the ignorant. Where 
washing is necessary, it may be done with bran water, milk and water, 
or starch and water, to which borax (a teaspoonful to the quart) may be 
added. The clothing should not be so excessive as to keep the child con- 
stantly in a perspiration. Napkins should not be washed in strong soda 
solutions, nor, in case of eczema of the buttocks, should they be used a 
second time after being simply dried. 

* While the citrate can not be depended upon as a diuretic, unless dispensed from 
a newly-opened bottle, it is generally to be preferred, as being more easily administered. 



ECZEMA. 869 

In eczema of the face it is absolutely necessary to prevent the child 
from scratching the parts. The use of a mask is not always sufficient, 
nor the wearing of mittens ; nor is the local application of anti-pruritic 
lotions or ointments invariably successful. In severe cases mechanical 
restraint is absolutely indispensable. The most satisfactory method is to 
surround the arms at the elbows by pasteboard splints, and hold them in 
]3lace by bandages. This allows free use of the hands, but makes it abso- 
lutely impossible for the child to reach the face. 

Local treatment. — Local treatment is always necessary, for not only 
are the causes sometimes entirely external, but the condition may persist 
after the original internal cause has been removed. There are several 
indications to be met by local treatment at different stages in the disease : 
(1) To remove crusts and other inflammatory products; (2) to allay con- 
gestion and acute inflammation ; (3) to relieve itching ; (4) to protect the 
delicate new skin which is forming ; (5) to prevent infection ; (G) to stimu- 
late the skin in the chronic stages of the disease. 

Preparatory to the use of any application, the scales, crusts, and other 
products of inflammation must be softened and removed in order that the 
diseased surface may be reached. In most cases it is sufficient to soften 
the crusts by the use of olive oil for twelve or twenty-four hours, and then 
remove them by soap and warm water. If the crusts are very hard and 
thick, they can be softened by a poultice. During the stage of acute in- 
flammation only sedative applications should be used. One of the best of 
these is a lotion of zinc and calamine : 

^ Pulv. calamine preparatao 3 i j 

Zinci oxidi 5 ss - 

Glycerinae 3 .1 

Liquor calcis 3 U 

Aquae rosae 3 V 'U- 

A piece of muslin should be dipped in this solution, and applied to 
the affected part, being kept in place by a bandage. If there is much 
itching, one per cent of carbolic acid may be added. 

Another plan of treatment, where there is much secretion, is fco keep 
the surface covered with equal parts of boric acid and starch or the 
stearate of zinc. An application which is often successful in allaying the 
intense burning and itching is black wash. 'This is applied with absorbent 
cotton for ten or fifteen minutes several times a day, and allowed to dry 
on, after which a protective ointment is used. If the black wash in full 
strength is painful, it may be diluted with water, [chthyol may he use.] 
in the same way, but only in dilute solution i. e., from one half to one 
per cent. 

As a simple protective ointment to follow any of the above, one con- 
taining starch, zinc oxide, or bismuth, either alone or in combination, may 
be used. An excellent formula is Lassar's paste : 



870 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

]J Acidi salicylici gr. x 

Zinci oxidi 3 ij 

Amyli 3 ij 

Vaseline § j 

Later, when the inflammation is less acute and the itching severe, 
nothing is so generally useful as a combination of tar and zinc, as in 
the following : 

]£ Ungt. picis liquidae 3 iij 

Zinci oxidi 3 iss. 

Ungt. aquae rosae 3 vi 

For more chronic cases, the amount of tar may be increased. All 
ointments used should be spread upon muslin, and kept in close contact 
with the inflamed part by means of a bandage or mask. Little or noth- 
ing is accomplished by simply rubbing the ointment upon the affected 
part. Where it is difficult to keep a mask applied, or in situations 
where it is impossible to use the ointment, Pick's paste may be tried : 

I£ Pulv. tragacantha? 3 j 

Glycerinae 3 iss. 

Aquae rosae § iv 

To this may be added zinc oxide gr. xl and carbolic acid gr. v, or tar TT[ x. 
A similar basis for ointments, made from gum tragacanth has been sug- 
gested by Elliot and is known as bassorin paste. It may be combined 
with tar, zinc, salicylic acid, or resorcin. 

The methods of treatment above mentioned are especially applicable 
to eczema of the face and scalp. For pustular eczema of the scalp the 
best application is the white-precipitate ointment, which should be com- 
bined with three or four parts of vaseline. This is excellent also for small 
eczematous patches upon the body, but it is not to be used over a large 
surface. 

In intertrigo, the treatment should have reference to the pathological 
condition which is present. Cases of simple erythema usually yield 
promptly to cleanliness and the free use of absorbent antiseptic powders, 
such as boric acid and starch in equal parts. If there is an acute derma- 
titis, the calamine and zinc lotion may be used, and later some protecting 
ointment. When infection has been added, lotions of resorcin or ich- 
thyol, one half or one per cent strength, should first be applied, and the 
skin then covered with the powder mentioned ; both are to be repeated as 
often as the parts are wet by urine or soiled by faeces. It is important 
in all cases that the diseased surfaces should be kept separated, which is 
best done by starch and absorbent cotton.- All napkins should be imme- 
diately removed when soiled. Other useful applications are Lassar's paste 
and Pick's paste combined with zinc oxide. 

In cases of chronic eczema, where the skin remains thickened, red, 



FURUNCULOSIS. 871 

scaly, and itching, stimulating applications are to be used, such as the 
tincture of green soap or stronger preparations of tar than those men- 
tioned. They should be applied every three or four days. 

In the seborrheic form of eczema, whether affecting the face, scalp, or 
body, 'nothing is so generally useful as resorcin : 

5 Resorcin. gr. x 

Ungt. aquae rosee § j 

This may also be advantageously combined with bassorin paste. 

FURUNCULOSIS. 

A furuncle, or boil, is a circumscribed inflammation of the subcuta- 
neous cellular tissue, beginning in a hair follicle, sweat gland, or sebaceous 
gland, and usually ending in suppuration. When severe, it may result in 
necrosis of the follicle, which forms the " core," or the necrotic process 
may extend to the surrounding tissues for a variable distance. The ordi- 
nary boil need not be described, as it presents nothing peculiar in early 
life. The condition, however, which is characteristic of young children is 
the formation of small ones in great numbers. It is to this more espe- 
cially that the term furunculosis is applied. The principal seat of these 
small abscesses is, in nearly all cases, the scalp, face, and shoulders, al- 
though they may be found upon any part of the body. They are sometimes 
numbered by hundreds, and appear in crops for a period of several months. 
In size, they usually vary from a pea to an almond, and they rarely con- 
tain a core. Infants are much more often the subjects of this disease 
than are those who have passed the second year. In the great majority 
of cases the condition is not serious, yet, occurring, as it often does, in 
infants who are already suffering from extreme malnutrition or marasmus, 
whose tissues possess but little resistance, the process may develop into a 
gangrenous dermatitis, which may prove fatal. 

Furunculosis is seen in children who are in other respects apparently 
healthy, even robust; but the majority are in a more or less debilitated 
condition, and often are the subjects of digestive disturbances. The dis- 
ease is quite frequent in syphilitic infants ; but these simple abscesses are 
to be sharply distinguished from those which result from the breaking 
down of gummata of the skin. Want of cleanliness of the skin is a factor 
of some importance in producing the disease. Furunculosis may be . 
ciated with eczema. The exciting cause in nil ca mown bj the 

recent investigations of Escherich and others, is the entrance of pyogenic 
germs, usually the staphylococcus aureus, into the follicles of the skin. 

Treatment.— The internal treatment is to he directed toward any dis- 
turbance of digestion or general nutrition which is present General 
tonics are indicated in most cases, particularly iron, arsenic, and the i 
pound syrup of the hypophosphites. But little reliance can he placed 



872 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

upon internal remedies, such as sulphide of calcium, for the purpose of 
arresting this disease. Local treatment should have for its first object 
thorough cleanliness of the skin. This is best secured by frequently bath- 
ing the parts affected with a saturated solution of boric acid. Single 
furuncles may often be aborted by the frequent application of spirits of 
camphor, or a few applications of tincture of iodine, or by touching them 
with pure carbolic acid. The last mentioned, although efficient, can hardly 
be intrusted to the hands of a mother or nurse. A remedy which has been 
used with considerable success is a plaster of salicylic acid. In my ex- 
perience the best plan of treating the multiple small furuncles, is to delay 
incision until they have pointed, then to incise freely and empty the follicle 
completely by compression. It is then washed out thoroughly with a 
solution of bichloride (1 to 2,000), and small pledget of absorbent cotton 
applied till the bleeding has ceased. After this the part should be covered 
with simple collodion or that in which iodoform has been dissolved. Where 
the abscesses are of large size and upon the scalp, it is wise to make com- 
pression by applying a snug bandage for a day. It is very exceptional for 
abscesses so treated to refill. When the suppuration is more diffuse and 
there is necrosis of the cellular tissue, ichthyol, either in the form of an 
ointment or lotion (one to five per cent strength), is one of the best appli- 
cations. Early and free incisions must be practised in all such cases. 



GANGRENOUS DERMATITIS. 

This is not a frequent disease, and is seen almost exclusively in in- 
fancy. It may be primary or it may follow other diseases, and hence has 
been described under many different names — viz., varicella gangrenosa, 
ecthyma gangrenosa, pemphigus gangrenosa, etc. 

The lesion consists in small, discrete areas of inflammation of the skin, 
ending in necrosis. In the primary cases there is usually first seen a vesi- 
cle, about as large as a pea, with a dusky areola ; it increases in size and 
becomes a pustule. Crusts form which are quite adherent, and on re- 
moving them a loss of tissue is seen. The ulcers usually have sharp but 
not undermined edges, often presenting a " punched-out " appearance. 
By the coalescence of several small ones, ulcers an inch or more in diame- 
ter are sometimes formed. 

The primary form of gangrenous dermatitis occurs in wretched, poorly- 
nourished infants, and, according to Elliot, is most often seen upon the 
buttocks. In this location it may be mistaken for syphilis. The second- 
ary form is more common, and usually follows varicella, less frequently 
vaccinia, measles, or pemphigus. My own experience with this disease has 
been confined to cases following varicella. In such, the lesion is usually 
seen upon the upper half of the body, especially upon the neck and chest. 
It follows the ordinary lesions of varicella and continues usually, in spite 



IMPETIGO CONTAGIOSA. gf3 

of treatment, from one to four weeks, in most cases ending fatally. The 
disease always occurs in infants of poor vitality, often in those suffering 
from marasmus, and is seldom seen outside of institutions. ' It may be 
accompanied by fever, and other severe constitutional symptoms. 

For the production of the disease, two factors are necessary : first, the 
constitutional condition referred to ; and, secondly, the entrance of pyo- 
genic germs, usually the streptococcus pyogenes. 

Treatment. — Every means possible should be employed to build up the 
general health of the infant by tonics, fresh air, careful feeding, etc. Lo- 
cally, strict cleanliness and antiseptic applications are necessary. The best 
application is a solution of bichloride (1 to 5,000), or an ointment of ich- 
thyol or iodoform. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is a disease characterized by the formation of dis- 
crete vesiculo-pustules, occurring most frequently upon the hands and 
face. Cases are usually seen in groups affecting several children in one 
family or institution. It may be communicated from one person to 
another, and spread by auto-inoculation from one part of the body to 
another. 

One rarely has an opportunity to see the disease until vesicles have 
formed. These are usually from one fourth to one half an inch in diame- 
ter, and are flaccid, never distended. Later, their contents become slightly 
yellowish; then they rupture and dry, forming thick yellow crusts, which 
have the appearance of being "stuck on," the surrounding skin being 
quite healthy. After the crusts fall off, a small red patch remains, which 
slowly fades. The true skin is not involved, except in poorly-nourished, 
cachectic subjects, as a result of continued local irritation, like scratching. 
Under such conditions ulceration may occur. Instead of the small vesic- 
ulo-pustules described, bullae from one to two inches in diameter may 
form, filled first with serum, afterward with sero-pus. Very little inflam- 
mation is seen about these patches, and in most cases the intervening skin 
is normal. 

The favourite seat of the eruption is the face, especially abonl the chin, 
next the hands, the neck, the feet and legs, the forearms, and tie- scalp; 
it is rarely seen upon the abdomen, and never up. .11 the back. There may 
be only half a dozen vesiculo-pustules, or from thirty to forty may be 
present. The smaller ones sometimes coalesce and form others of consid- 
erable size. Itching is never a prominent symptom, and in mosl cases n 
is absent altogether. 

The usual duration of impetigo contagiosa is two <>r three weeks; it, 
however, runs no regular course, and by continued auto-rinoculation may 
last much longer than this. 

The disease is undoubtedly due fcosome form of local bacterial infection. 



874 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

but the exact nature is not yet determined. It may occur in any child, 
but is usually seen in one who is cachectic and poorly nourished. 

The diagnosis is not often difficult, and is made by the following fea- 
tures — viz., the occurrence of several cases together, the isolated vesiculo- 
pustules situated upon the face and hands, the slight itching, and the 
prompt cure by local measures only. The bullous form, however, is some- 
times confounded with pemphigus, and there are cases in which the differ- 
ential diagnosis may be quite difficult. 

Treatment. — This is simple and usually very effective. The crusts are 
to be softened and removed by thoroughly washing the part with soap and 
water or a bichloride solution, after which the white precipitate ointment, 
combined with three parts of vaseline, should be applied. 

URTICARIA. 

Urticaria is a frequent disease in early life, and presents some features, 
particularly in infants and young children, which are quite different from 
those seen in adults. ( This is due to the fact that papules and vesicles, 
and occasionally pustules, are associated with the wheals. As the wheals 
quickly subside, it frequently happens that the other lesions mentioned 
are the only ones present. This fact has given rise to considerable con- 
fusion in names, and the urticaria of infancy has been called lichen 
urticatus, urticaria papulosa, strophulus, etc. It is now pretty generally 
agreed that the clinical picture, which is a familiar one, belongs to a single 
disease, and that this is urticaria. 

The initial lesion is the wheal, but on account of the extreme suscepti- 
bility of the skin in young children, the process is more intense than in 
older patients, so that it may result in the formation of an inflammatory 
papule or a vesicle. In a few hours the wheals may subside, and only the 
papules or vesicles remain, and without a good history the disease may be 
a very obscure one. The papules and vesicles occur with greatest fre- 
quency upon the hands and feet, particularly the palms and soles. The 
more severe form of the disease in poorly nourished children is sometimes 
accompanied by a pustular eruption, and there may even be deep ulcera- 
tion (ecthyma). The usual appearance of the eruption is a number of 
small inflamed red papules whose tops are covered with scabs, the result of 
scratching. The eruption may be limited to the extremities or it may be 
general. It is as a rule more severe in regions accessible to scratching. 

There is usually severe itching, which leads to loss of sleep, and often 
in this way the disease affects the general health of the child. The urti- 
caria of older children does not differ essentially from the same disease in 
adults. 

The character of the eruption in urticaria and even its distribution 
strongly suggest scabies ; and unless one has had an opportunity to witness 
the development of the lesions, a differential diagnosis may be very difficult, 



SCABIES. 875 

as almost every lesion, except the wheal, may be identical in both diseases. 
Other cases may resemble varicella. 

Urticaria in early life is most frequently the result of some disturbance 
in the digestive tract. Almost any sort of derangement may produce it, 
the exciting cause varying with the patient. Exceptionally, it may result 
from other forms of irritation, such as dentition or intestinal worms, and 
it has been ascribed to malarial poisoning. 

Treatment. — The milder forms of urticaria usually respond quickly to 
treatment ; but when it is severe and has existed for several weeks, it is 
one of the most troublesome and intractable skin diseases of childhood. 
The treatment is to be directed primarily toward the condition of the 
digestive organs. Children should be put upon a milk diet, and even 
milk may need to be partiallv peptonized. The bowels should be kept 
freely open by calomel, a nightly dose of castor oil, or a morning dose of 
magnesia. If the urine is excessively acid and scanty, alkaline diuretics 
should be given. The drugs most useful for the indigestion with which 
urticaria is associated are salicylate of soda and nitro-muriatic acid, each 
of which is to be given after meals. 

All local causes of irritation, such as rough flannel underclothing, 
should be removed. The sleep may be so much disturbed as to require 
the use of trional or bromide and chloral. The two remedies which are 
of most value for the disease itself are antipyrine and atropine; they may 
be used separately or in combination, and should be administered in mod- 
erately large doses. 

The local irritation and itching may be relieved by a lotion of menthol 
(gr. ij, water § j), by a very dilute solution of the subacetate of lead or 
carbolic acid, or by a mixture of vinegar, or the fluid extract of hamamelis, 
and water. Where pustules are present, the white-precipitate ointment 
maybe used, combined with four parts of vaseline; in the papular and 
vesicular forms, an ointment of ichthyol or naphthol, one per cent strength. 
In many cases the improvement in the general health by the use of tonics, 
change of air, etc., will accomplish more than any measures directed 
especially to the relief of the urticaria. 



SCABIES. 

Scabies is a contagious disease due to tin 1 burrowing into the skin of 
the female acarus, with secondary lesions which resull from scratching. 
This disease is not a common one in New York, even among dispensarj 

patients, while among the better classes it is extremely rare. 

The burrowing of the acarus is usually where the skin is thinnesl 
viz., between the fingers, on the flexor surfaces of the wrists, the axilla-, 
and, in males, the genitals. It is not aeeu upon the face, except in infancy, 
when it may be infected by contact with the breasts of the mother. 



876 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

The lesion excited by the acarus is usually a papule or a vesicle, sometimes 
a pustule. In some cases no evidences of inflammation are present, but 
in infants and young children they may be marked, — pustular eruptions 
being frequent and often extensive, especially upon the hands and feet. 
The characteristic burrow is from one fourth to one half inch in length, 
and appears as a fine brown or black line, at the end of which the acarus 
may be discovered as a small white speck. The burrows are often difficult 
to find in infants. They are generally to be seen along the inner border 
of the hand and between the fingers. The intensity of the inflammatory 
lesions varies greatly in different cases ; in some they are very few, while 
in others, particularly in delicate, cachectic, and neglected children, they 
are sometimes very severe, so that the skin of the affected part is nearly 
covered with pustules. This is especially true of the hands, where a 
pustular eruption should always suggest scabies. The lesions which result 
from scratching may be found on any accessible portion of the body. There 
are usually at first linear, bloody marks, but after a time these may not 
be visible, and there may be only a traumatic eczema. In little children 
urticaria is often associated. 

The diagnosis of scabies is usually quite easy, as several children in a 
family are likely to be affected, particularly if they occupy the same bed. 
The diagnostic features of the eruption are the presence of papules, vesi- 
cles, or pustules, especially upon the hands, wrists, and genitals. A care- 
ful examination with a lens will usually disclose some of the character- 
istic burrows, or even the acarus. In infancy, scabies may be easily con- 
founded with the vesicular form of urticaria, unless the development of 
the lesions has been observed. 

Scabies may always be cured, provided sufficient precautions are taken 
to prevent re-infection. This necessitates boiling or baking, not only the 
patient's clothes, but all the bedding as well. 

Treatment. — This should always be begun by a hot bath, in order to 
soften the epithelial scales about the burrows. The body should be thor- 
oughly scrubbed with soap and water, preferably with a nail-brush, the 
bath being continued for at least half an hour. It is well to do this at 
night. After the bath, the body is anointed with the parasiticide, which 
should be thoroughly rubbed into the skin, clean clothing applied, and 
the child put into a perfectly clean bed. In the morning the ointment 
may be washed off, but none of the clothing previously worn should be 
put on. This treatment is to be repeated on two or three successive 
nights, and if thoroughly done it will effect a cure. The ordinary sulphur 
ointment is too irritating for use in little children, and one of the fol- 
lowing may be substituted : naphthol, 15 parts; creta preparata, 10 parts; 
vaseline, 100 parts (Kaposi) ; or, precipitated sulphur, 1 part ; balsam of 
Peru, 1 part ; vaseline, 8 parts ; or the simple balsam of Peru may be ap- 
plied without dilution. After the use of the parasiticide there is generally 



TINEA TONSURANS. 377 

required for a few days, some soothing application like those mentioned 
in the chapter upon Eczema. 

TINEA TONSURANS— RING-WORM OF THE SCALP. 

Eingworm of the scalp is a very frequent disease in institutions for 
children, often occurring as an epidemic. According to Crocker, the 
primary lesion consists in a red papule surrounding a hair, which soon 
increases to a small circular patch ; this spreads at its outer margin, 
gradually increasing in size until it is from one to two inches in diameter, 
but rarely larger than this. Sometimes several of the patches coalesce. 
These affected areas always have rounded borders, and are sharply out- 
lined. Here the hairs are very brittle, and often broken off close to the 
scalp, so that it may appear to be bald. Where they have not fallen off, 
the hairs have lost their lustre. The stumps of the broken hairs point in 
all directions. 

The fungus which produces the disease is the trichophyton tonsurans. 
It penetrates the shaft of the hair, both the spores and the mycelium 
being seen under the microscope. The spores are present in great num- 
bers in the hair, but the mycelium is most abundant in the scales: The 
amount of inflammation found in the diseased areas varies much in the 
different cases. There may be only a scaliness of the scalp, or a formation 
of pustules in the hair follicles, the hairs loosening and falling out in con- 
sequence. In young infants where the hair is scanty and thin, the dis- 
ease resembles tinea circinata — i. e., it is superficial, and the hair follicles 
are often not involved. Children of all ages are liable to tinea ton- 
surans. It flourishes particularly in those who are dirty and poorly 
cared for. 

The diagnostic feature of the disease is the presence of scaly patches, 
with loss of hair. The patches are usually circular, and by examination 
with a lens the stumps of broken hairs are seen all over the diseased 
area. By a microscopical examination the fungus is discovered. In 
typical cases the diagnosis is easy if the process is at all advanced, hut 
there are many atypical forms and many mild cases where the recogni- 
tion of the disease is difficult. The symptoms are often masked by the 
inflammatory conditions present. The; disease may be confounded with 
seborrhcea; but in the hitter the lesion is diffuse, never sharply defined ; 
there is general thinning of hair over the scalp, and never the stumpy, 
broken hairs. Psoriasis has points of resemblance, hut it is usually found 
on other parts of the body, especially the knees and elbows, and upon the 
scalp the patches are more numerous and smaller. In eczema tic lose of 
hair in circumscribed patches is never seen, nor are the broken Mumps. 

Tinea tonsurans is always curable, provided the patient can be kepi 
under close surveillance, and treatment thoroughly carried out. There is 
no tendency to spontaneous recovery. In a recent case, treatment must 



878 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

usually be continued for one or two months, and in chronic cases, from 
six months to one year, with the closest watchfulness. 

Treatment. — The great difficulty in treatment is to get the parasiticide 
deeply enough into the scalp to reach the fungus, since this is often at the 
very bottom of the hair follicles. As a first step, the hair should be cut 
short all over the patch and for at least an inch beyond it ; this is neces- 
sary in order to get at the diseased part and to detect new foci of infection 
early — if possible before the fungus has extended deeply into the follicles. 
The parasiticide should be applied not only upon but around the patch, 
and the entire scalp should be washed thoroughly two or three times a 
week. To prevent the disease spreading, all the scales are to be kept soft- 
ened by the use of carbolic soap. The hair should not be brushed, as this 
tends to scatter the spores and spread the disease. All patients while 
under treatment, should wear a cap of muslin or oiled-silk, or one lined 
with paper, in order to prevent infecting others. In institutions, aifected 
children should invariably be isolated. 

To destroy the fungus almost every germicide on the list has been 
advocated at one time or another, which proves that the disease is a very 
obstinate one, and that no one application is invariably successful. Those 
which have the sanction of the widest use are the tincture of iodine, the 
bichloride, white precipitate, and oleate of mercury, kerosene, creosote, 
and croton oil. As a vehicle for ointments, lanoline is greatly to be pre- 
ferred to vaseline or lard ; according to Crocker, the addition of three 
parts of lanoline to one part of olive oil is much better than lanoline 
alone. Most of the germicides mentioned are used in the strength of one 
to five per cent, according to the age of the child and the irritability of 
the scalp. In an epidemic of ring- worm in the New York Infant Asylum 
the following combination of bichloride and kerosene proved extremely 
satisfactory : ten grains of the bichloride were dissolved in alcohol, and 
to this were added two and a half ounces each of olive oil and kerosene. 
This was applied every day, being thoroughly rubbed into the diseased 
patches, and the whole scalp saturated with it. Considerable irritation 
usually resulted, and every few days the parasiticide was omitted and some 
simple emollient applied until the irritation had in a measure subsided. 
In some of the cases, the tincture of iodine was alternated with the bichlo- 
ride and kerosene. Twenty-six cases were treated after this plan and all 
cured, the average duration of treatment being eight and a half weeks.* 

Epilation is necessary in many cases as an accessory to the application 
of germicides, particularly in older children. 

* A full report of these cases was made by C. G. Kerley, M. D., in the New York 
Medical Journal, October 10, 1891. 



ACUTE OTITIS. 879 

CHAPTER VI. 

ACUTE OTITIS. 

Otitis is a frequent affection during infancy and early childhood, at- 
tacks usually occurring in the cold season. Of all the inflammatory con- 
ditions which may be met with in early life, there is perhaps none which 
more frequently gives rise to obscure febrile symptoms than this. 

Etiology. — Acute otitis, as a rule, is a secondary disease, and is generally 
preceded by some infectious process in the rhino-pharynx. The usual 
avenue of infection is through the Eustachian tube. The catarrh of the 
pharynx may be a simple one, the ordinary head-cold, or it may occur as 
a complication of the acute infectious diseases. Downie gives the follow- 
ing statistics of 501 cases of tympanic involvement treated in the Chil- 
dren's Hospital in Glasgow : 

Originated during measles 131 cases, or 26-1 per cent. 

" scarlet fever 63 " " 126 li " 

" " whooping-cough 15 " " 3*0 * k 

" " mumps 3 " " 06 " " 

" " simple catarrh 147 " " 29-4 " " 

" dentition 101 " u 20 " " 

Syphilitic 8 " " 16 " " 

Doubtful 33 " " 6-7 " " 

501 100-0 

The most common condition preceding severe otitis is scarlet fever, 
and next in the order of their frequency, epidemic influenza, simple acute 
pharyngitis or tonsillitis, measles, diphtheria, and typhoid fever. Otitis 
when following simple inflammations of the throat is usually much less 
severe than when it complicates scarlet fever or diphtheria. Cold and 
exposure frequently play the role of exciting causes. In a few eases the 
disease is the result of traumatism, such as a blow or traction upon the 
external ear, or the entrance of fluids through tli- Eustachian tune from 
the nasal douche. It sometimes results as an extension of inflammation 
from meningitis, especially the cerebro-spinal form. When seen as a com- 
plication of scarlet fever, measles, or diphtheria, the symptoms arc usually 
manifested from the sixth to the tenth day of the disi 

Lesions.— The ordinary course of events in the pathological proc< 
first, acute hyperemia and swelling of the mncoua membrane of the 
rhino-pharynx, which extends into the Eustachian tube, causing ob- 
struction more or less complete. The inflammatory process may he lim- 
ited to the tube, or it may extend to the mucous membrane lining the 

middle ear. 

There are two varieties of acute inflammation of the middle ear : (1) 



880 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

The catarrhal form, which usually accompanies simple catarrh of the 
rhino-pharynx or complicates measles. This is an inflammation- of the mu- 
cous membrane merely, and its products are serum and mucus or muco-pus. 
It is not usually accompanied by great pain or followed by serious conse- 
quences. It is generally confined to the lower part of the tympanic cav- 
ity, and is the form most frequently seen in infants. (2) The phlegmonous 
form, which affects older children principally. This is a much more se- 
rious inflammation, and is often excited by the infectious catarrh of scarlet 
fever, diphtheria, or epidemic influenza. In this variety micro-organisms 
find their way into the middle ear in great numbers, and set up an inflam- 
mation of a more or less virulent type, which involves not only the mu- 
cous membraue lining the tympanum, but also the cellular tissue in the 
upper part of the tympanic cavity. 

The catarrhal form of inflammation frequently subsides in a few days 
with proper treatment, the only result being a slight deafness, which is 
temporary. The phlegmonous form causes a stoppage of the Eusta- 
chian tube, rupture or sloughing of the tympanic membrane and dis- 
charge of the products of inflammation, or rarely pus finds an outlet by 
burrowing along the cartilages. The inflammatory process may extend to 
the bones, causing necrosis of the ossicles or the bony walls of the tym- 
panum. The remote results are periostitis and necrosis of the petrous 
bone, pachymeningitis, infectious thrombosis of the lateral sinus, general 
purulent meningitis, and cerebral abscess. These will be considered under 
Complications. 

Symptoms. — These are usually few in number, but present great varia- 
bility as regards their combinations and intensity. The two* most con- 
stant symptoms are pain and fever. In a typical case in an infant, there 
is generally at the beginning some discharge from the nose, slight conges- 
tion of the pharynx and tonsils, and a temperature of 100° to 102° F. 
There is nothing characteristic about this catarrh. After two or three 
days the objective symptoms subside, but the infant continues to be rest- 
less, worries much of the time, wakes frequently at night with a start, 
nurses poorly, and if the thermometer is used, it is found that the tempera- 
ture remains elevated, usually from 99° to 101° F. The infant seems de- 
cidedly ill, and yet no very definite symptoms are present. Sometimes 
there is marked tenderness about the ear, and the child refuses to lie upon 
the affected side, or shows signs of pain when the ear is touched. After a 
week or ten days a discharge is found in the auditory canal, and usually 
there follows a rapid subsidence of the constitutional symptoms. In some 
cases there is seen only a high temperature, ranging from 101° to 104° F., 
which persists for several days without outward evidences of pain or other 
signs of inflammation, the discharge being the first symptom which leads 
the physician to suspect disease of the ear. In other cases there are 
marked dulness, apathy, anorexia, and sometimes nausea and vomiting, 



ACUTE OTITIS. 8S1 

but for several days no evidence of pain ; the temperature may be but 
little elevated. Thus, in most of the attacks seen in infancy, pain is not 
very marked, and it is this which so often leads to the great obscurity of 
the symptoms. 

In older children the symptoms are more characteristic. Pain is usu- 
ally sharp and severe, and is complained of early in the attack. The 
temperature is nearly always elevated two or three degrees, and occa- 
sionally it is 103° or 104° F., with severe headache, extreme restlessness, 
and even delirium or convulsions, so that meningitis may be suspected. 

The inflammation does not necessarily go on to suppuration and rup- 
ture. There are even more frequently seen, accompanying ordinary head- 
colds or mild attacks of influenza, cases in which the pain is quite severe 
for twenty-four or thirty-six hours, and accompanied even by a moderate 
elevation of temperature, and yet which rapidly subside without further 
symptoms. In these cases the pain is too constant and too prolonged to 
be an attack of neuralgia. They are simply cases of a mild form of in- 
flammation. 

In infants suffering from malnutrition or marasmus, otitis not infre- 
quently comes on without any objective symptoms, the first thing noticed 
being the discharge. This association of otitis with marasmus is to be 
attributed to the frequency of swelling of the adenoid tissue in the phar- 
yngeal vault, upon which the catarrhal process depends. 

Of the individual symptoms, fever is the most constant, and is present 
in all except the cases of marasmus just mentioned. The usual range of 
temperature is from 100° to 102° F. ; exceptionally it may be from L03 
to 105° F. The course of the temperature is irregular and remittent. 
After spontaneous rupture or incision of the drum membrane the tem- 
perature usually falls, but often not immediately; occasionally it con- 
tinues almost as high as before for twenty-four hours. Pain is more 
marked in older children than in infants: first, because in the latter the 
drum membrane is not so firm, yields more readily, and ruptures earlier; 
and, secondly, because the inflammation is usually of the catarrhal and not 
the phlegmonous type. Tenderness is sometimes elicited by pressure just 
in front of the external auditory meatus ; there may be increased sensitive- 
ness of all parts of the ear and even of the whole side of the head. Chil- 
dren not infrequently complain of noises in the ear. One little girl with 
obscure symptoms and high temperature, first called attention t<> her ear 
by the remark, that she "heard pussy in the room." A sense of discom- 
fort resembling that which is felt when the eai opped, frequently 
leads children to pick at them. Cerebral symptoms an- infrequent, and 
occur chiefly in cases not receiving proper early treatment ; they are | 
tically limited to the phlegmonous form of inflammation, and they may 
indicate meningeal congestion, less frequently localized meningitis 
thrombosis. n „ 



882 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

The local appearances in the early stage — provided a view of the 
tympanic membrane can be obtained — are acute redness and congestion ; 
later there is distinct bulging of the membrane. If perforation has taken 
place, its site may or may not be visible, but, according to Pomeroy, its 
existence may always be assumed, if there is pulsation of the membrane, 
if bubbles of air are seen deep in the canal, if the perforation whistle 
occurs upon blowing the nose or inflating the ear, and, finally, if much 
mucus or pus is present, as inflammation of the external canal almost 
never causes much discharge. A discharge is not present until perfora- 
tion has taken place. The pus in rare cases may burrow along the car- 
tilages and open externally behind or at the side of the ear. The nature 
of the discharge depends upon the variety of the disease ; in the catarrhal 
form it is at first sero-mucus, whitish in colour, rather thick, quite profuse, 
and usually continues when once established ; later it is usually purulent. 
In the phlegmonous form it is always purulent, generally less abundant, 
and liable to a sudden arrest with an exacerbation of the constitutional 
symptoms. As the case improves the discharge diminishes in quantity 
and gradually assumes a serous character. 

Diagnosis. — In typical cases characterized by pain and temperature, 
this is usually easy, particularly in older children. Otitis in infancy is 
frequently obscure, sometimes because the patient is too young to direct 
attention to the seat of pain, but more often because the pain is slight or 
entirely absent. The temperature is almost invariably elevated, and the 
usual problem presented to the physician is to discover a cause for this 
fever. In the absence of definite otoscopic signs, one must rely upon the 
presence of faucial congestion, a history of a previous acute catarrh, rest- 
lessness at night, and the absence of other signs in the throat, lungs, or 
digestive tract, which might explain the fever. Local tenderness, deaf- 
ness, or noises in the ears are of much significance when present, but they 
are very often wanting. Otitis is so common a cause of high temperature 
in infants during the cold season, that one should always be on the look- 
out for it. In older children a neuralgia arising from a carious tooth may 
give rise to a pain resembling that of otitis. 

Prognosis.— The ordinary catarrhal form of acute otitis is not often 
followed by serious consequences, unless there are repeated attacks. The 
phlegmonous form, especially when it complicates scarlet fever, is always 
serious, and in the majority of cases it is followed by some degree of im- 
pairment of the sense of hearing. 

Complications and Sequelae.* — Remote consequences are most likely to 
be seen in cases following scarlet fever, probably because of their severity, 
particularly when early treatment has been neglected. In many cases 
the symptoms are obscure- because the discharge from the ears has been 

* See Pitt's Gulstonian Lectures, 1890. 



ACUTE OTITIS. 



883 



slight or wanting. It is to be remembered in this connection that the 
Eustachian tube, middle ear, and antrum, in young children are relatively 
large, and hence easily infected, while the mastoid cells are imperfectly 
developed. These anatomical conditions explain the greater frequency 
of extension of the disease to the petrous bone and the brain, and, as 
compared with adults, the infrequency of mastoid complications. 

Meningitis. — This may be a cause of death in young children. There 
may be a localized pachymeningitis with the formation of pus, or a gen- 
eral purulent meningitis. It may be secondary to other lesions, such as 
thrombosis of the lateral sinus, or the rupture of a cerebral abscess, but 
is usually due to the passage of pus through the roof of the tympanum, 
or along the internal auditory meatus. Meningitis is more frequent as a 
complication of old cases, but may develop soon after the early acute 
symptoms. Its onset is usually sudden, and its duration rarely more than 
a week. 

Cerebral abscess. — This is due to a direct extension of the infectious pro- 
cess from the bone, vein, or dura mater. In about two thirds of the cases 
the abscess is in the temporo-sphenoidal lobe. The next most frequent 
seat is the lateral lobe of the cerebellum. Korner states that disease of 
the mastoid and middle ear leads to cerebral abscess, and disease of the 
labyrinth to cerebellar abscess. Abscesses may be complicated by throm- 
bosis or by meningitis. They are often latent until just before death, 
which more frequently occurs from 
the development of purulent menin- 
gitis than from any other cause. 
They are rare except in cases of 
long standing. 

Thrombosis of the lateral sinus 
occurs as a condition antecedent to 
meningitis or abscess, or without 
them. It usually develops suddenly, 
with recurring chills and a high 
temperature, which is subject to 
sudden and wide fluctuations. 

Mastoid disease, as previously 
stated, is not so frequent a compli- 
cation of otitis in children as in 
adults, one reason being that the 
mastoid process contains but a sin- 
gle cavity, the antrum, whose walls 
are so thin that spontaneous rupture 
externally readily occurs, while the 
mastoid cells are very imperfectly developed until after puberty. Mastoid 
disease may accompany either acute or chronic otitis. There arc local 





Fig. L58. 



v 



884 DISEASES OF THE BLOOD, LYMPH NODES, BONES, ETC. 

pain and tenderness and a very characteristic swelling, which causes the 
ear to stand out from the head (Fig. 153). Usually the process ends in 
suppuration, with the symptoms of external abscess, but resolution some- 
times occurs. This may often be promoted by the early application of 
cold either in the form of an ice bag or a coil. 

The labyrinth is less frequently involved, although cases are recorded 
by Pye, Phillips, and others, in which the necrosis and discharge of the 
entire labyrinth has occurred after scarlet fever. In most of these cases 
the deafness was complete, and in several vertigo was present. 

Facial paralysis rarely occurs in the acute cases, but accompanies a 
considerable proportion of the chronic ones. It is due to an extension of 
the inflammatory process from the bone to the seventh nerve, where it 
passes through the canal. The symptoms are those of ordinary peripheral 
facial palsy. 

Treatment. — If the case is seen in the early stage, the inflammation 
may not infrequently be cut short by local blood-letting and the use of 
heat. Blood-letting is not to be advised in the case of young infants, but 
may be used in children over two years old. It should be urged in spite 
of its obvious disadvantages, as nothing is so efficient. Either leeches or 
wet cups may be employed. They should be applied just in front of and 
close to the tragus. Dry heat is to be preferred to moist heat, both as a 
means of arresting inflammation and of relieving pain. It may be applied 
by means of a bag of hot water, salt, or bran, or by a hot brick or soap- 
stone. These should be placed beneath a thin pillow, upon which the 
child's head rests. If the child will not lie upon his hot pillow, a small 
bag of salt or hot water may be bound over the ear, which has been first 
covered by cotton. Perhaps the best of all is Deuch's device of filling the 
tip of the finger of a kid glove with salt, and inserting this into the canal 
after heating ; cotton should be applied over it. Hot poultices may be 
used for a short time, being changed frequently, but prolonged or con- 
tinuous poulticing encourages suppuration and should never be allowed. 
On no account should oil, or oil and laudanum, be dropped into the ear, 
as is so often done in domestic practice. If the child is not comfortable 
in the course of a couple of hours after the blood-letting or dry heat, an 
opiate should be given. This not only relieves suffering, but has a favour- 
able influence upon the inflammation. 

A return of the severe pain on the following day, or its continuance in 
spite of ordinary measures, with a steadily high temperature, are indica- 
tions for operative interference. If to the above, cerebral symptoms are 
added, operation is imperative. An early incision of the drum membrane 
is usually followed by a discharge of blood only ; but tension is relieved 
and with it the pain disappears, and the inflammation often quickly sub- 
sides without the formation of pus. Much suffering is thereby avoided, 
and, as the wound heals quickly, much less damage is done than by allow- 



ACUTE OTITIS. 8S5 

ing the disease to go on to a spontaneous rupture. Later operation may 
be required either for the relief of pain or the evacuation of pus, in order, 
if possible, to prevent the disease from spreading to the bony parts. 

After incision or spontaneous rupture of the drum membrane, the pain 
usually ceases, although the temperature may not fall to normal for twenty- 
four or thirty-six hours, even with good drainage. The discharge is now 
the principal object of treatment. Nothing else is necessary than to keep 
the ear perfectly clean. The canal should not be plugged with cotton, 
nor should it be stopped by the insufflation of powders. It should be 
syringed with a solution of bichloride (1 to 5,000), or a saturated solution 
of boric acid, or simply with boiled water. All these fluids should be 
used warm, and, if the discharge is purulent and abundant, as often as 
every two or three hours — in all cases several times a day. A bulb ear- 
syringe of soft rubber is the most satisfactory instrument for general use. 
It is a mistake to keep the ears covered by a thick mass of cotton or flan- 
nel, as is so often done. In the house no protection is necessary. A sud- 
den rise in the temperature usually means that drainage is imperfect; if 
it is accompanied by pain, a second incision may be necessary. If the 
temperature remains high, one should be on the lookout for mastoid 
disease. 

In most cases the discharge ceases in from one to three weeks ; should 
it continue longer, some measures for checking it may be used. Bench 
advises as better than other applications, the use of a few drops of a satu- 
rated solution of boric acid in alcohol after syringing. It should be ap- 
plied with a medicine dropper. Where the discharge has become fetid, 
syringing once a day with a solution of peroxide of hydrogen (1 to 4, or 
even stronger) is often useful. A persistent discharge often depends upon 
the fact that the child's general condition is poor, and improvement 
in this will do more to stop the discharge than any variation in local 
treatment. 

One attack of otitis is frequently the precursor of many others. Chil- 
dren sometimes have one or more attacks every winter for several years. 
Such children are usually those who are very prone to catarrhal colds, and 
in most of them will be found adenoid vegetations in the pharynx. In 
order to get rid of this tendency to attacks of otitis, such growths Bhould 
be removed and all other associated pathological conditions treated. The 
nose should be kept as clean as possible by frequenl use of the hand 
atomizer with some mild cleansing solution, such as Dobell's or Setter's. 
The rhino-pharynx may be touched one- in two or three days with a solu- 
tion of nitrate of silver (10 to :5<> grains to the ounce). 

Cold sponging about the neck and chest should la- employed, as W( 1! 
as every means to reduce the susceptibility to acute catarrh. The remote 
dangers from these recurring attacks are often overlooked. They may be 
the beginning of a chronic condition, the full effects of which arc; not 



886 DISEASES OP THE BLOOD, LYMPH NODES, BONES, ETC. 

seen until adult life is reached, both the physician and the parents 
often thinking that all danger has passed when the acute symptoms have 
subsided. 

The treatment of chronic otitis and of the associated conditions is 
largely surgical, and belongs to the specialist ; but it is extremely impor- 
tant that the general practitioner should be familiar with their symp- 
toms, and realize the danger from these neglected cases, not only to the 
function of hearing, but also to life itself. The essential thing in treat- 
ment is to operate sufficiently to secure free drainage, and to permit thor- 
ough cleansing of the parts. Too much can not be said against the 
expectant treatment of these cases, or against the practice of prolonged 
poulticing. 



SECTION IX. 
THE SPECIFIC INFECTIOUS DISEASES. 

Accurate classification of the infectious diseases is at the present 
time impossible, but there are two quite distinct groups into which, with 
one or two exceptions, those here considered may be placed. 

The first group includes scarlet fever, measles, rubella, varicella, and 
pertussis. The nature of the specific poison in each of these is as yet 
unknown. They are, strictly speaking, contagious ; for it is practically 
certain that any of them may be contracted by proximity to a person 
suffering from the disease, without actual contact. In no one of these 
diseases is the poison given off in a single definite discharge, and in no 
one is there a characteristic visceral lesion. Mumps resembles the mem- 
bers of this group in all points except the one last mentioned. These pe- 
culiarities, together with the fact that thus far the poison of each of these 
diseases has resisted all attempts at isolation, render it not improbable that 
these poisons are some other variety of micro-organisms, and not bacteria. 

In the second group may be placed diphtheria, typhoid fever, and 
tuberculosis, in each of which the specific poison is a known form of 
bacteria. Each of these diseases is associated with definite and character- 
istic visceral lesions. The poison is discharged from the body in a certain 
well-understood manner from the tissues which are affected by the 
disease, and in no other way. These diseases can not be contracted by 
proximity to a diseased person, but only by receiving into the body the 
specific germs, either by contact with a person Buffering from the disease 
or contact with something npon which the special germs of the dia 
have been discharged. In other words, though communicable, they are 
not, strictly speaking, contagious. 

Syphilis, influenza, and malaria have not been included in either of the 
above groups. Syphilis must still be placed in the doubtful class, altho 
its general characteristics all y it with the second group. The fact thai a 
certain germ— Lustgarten's bacillus— ia quite nniformly found in syphi- 
litic lesions also points in the same direction; the evidence, however, 
is not conclusive that this bacillus la the cause of the disease. In its 
communicability, influenza resembles the first -roup, although then- is 
now little doubt that it is due to a form of bacteria— Pfeiffer'a bacillus. 

887 



S88 THE SPECIFIC INFECTIOUS DISEASES. 

Malaria belongs in a class by itself, differing in nearly all its essential 
features from the other diseases of this general group, as its specific 
poison is known to be a form of protozoa. 



CHAPTER I. 

SCARLET FEVER. 
Synonym : Scarlatina. 

Scaelet fevee is an acute, contagious, self -limited disease, one attack 
usually protecting the individual through life. The period of incubation 
is usually from two to six days ; that of invasion, from twelve to twenty- 
four hours ; that of eruption, from four to six days ; that of desquamation, 
from three to six weeks. The disease may be communicated at any time 
from the first symptom of invasion throughout desquamation, and some- 
times even during the existence of purulent discharges from the nose or 
other mucous membranes. It is usually ushered in by vomiting, high 
fever, and sore throat, and is characterized by an erythematous rash ap- 
pearing first upon the neck and spreading rapidly over the entire body. 
Its chief complications are otitis and membranous inflammations of the 
pharynx, which frequently extend to the nose, more rarely to the larynx. 
The most important sequelae are deafness and nephritis. 

Etiology. — Analogy leads to the belief that scarlet fever is due to a 
micro-organism, but as yet its nature has not been discovered. The com- 
plications are usually associated with the growth of the streptococcus 
pyogenes. Some have gone so far as to claim that this germ is the cause 
of the disease. From present knowledge, however, it appears rather to 
play the role of a secondary or accompanying infection, for the develop- 
ment of which the mucous membranes of a person suffering from scarlet 
fever seem to afford most favourable conditions. To the streptococcus 
may be ascribed the membranous inflammations of the tonsils and pharynx, 
the otitis, the inflammation of the lymph nodes and the cellular tissue of 
the neck, and probably also the nephritis, pneumonia, and joint lesions. 
In many of the above conditions, the streptococcus is associated with 
other pyogenic germs, and in some cases with the diphtheria bacillus. 

Predisposition. — The susceptibility of children to the scarlatinal poison 
is much less than to that of measles ; still, it is much greater than that of 
adults. Billington (New York) records observations made in twenty-six 
families living in tenements where little or no attempt at isolation was made. 
In these families there occurred 43 cases of scarlet fever ; but 47 other chil- 
dren, although unprotected by previous attacks and constantly exposed, 
did not contract the disease. 

Johannessen reports that of 185 children under fifteen years who were 



SCARLET FEVER. 



exposed, 28 per cent contracted the disease ; while of 314 adults, only 5 per 
cent contracted the disease. It may be stated that, approximately, not 
more than one half of the children exposed take the disease. The sus- 
ceptibility is not great in early infancy, but it increases until about the 
fifth year, after which it steadily diminishes. Both sexes are equally 
liable to scarlet fever. Epidemics are more frequent in the fall and win- 
ter than in summer, and cases occurring in the cold months are apt to be 
more severe. Whitelegge, in 6,000 cases, found the highest mortality in 
the month of October ; and in Caiger's report of 1,008 cases this was also 
the month showing the greatest mortality. 

Incubation. — Of 113 cases* in which the period of incubation could 
be accurately determined, it was as follows : 

8 days 2 cases. 



24 hours or less 6 cases. 



2 days 

3 " 

4 " 

5 " 



15 
28 
25 
6 
15 



5 " 
1 case. 
1 »' 

1 " 

113 cases. 



Thus in 87 per cent of these it was between two and six days, and in 
66 per cent between two and four days. The incubation is rarely over a 
week ; it is particularly short in surgical cases, a well-authenticated in- 
stance being on record in which it was but six hours. Speaking gener- 
ally, if, after exposure, a week passes without symptoms, the chances of 
infection are very small. A short incubation is more frequently seen in 
severe than in mild cases. 

Mode of infection.— The chief source of infection is the patient him- 
self. It is somewhat doubtful whether the poison of Bcarlet fever can be 
conveyed by the breath, but it may be by discharges from the mucous 
membranes involved, from the scales during desquamation, and probably 
from all the excretions,— urine, fasces, and perspiration of the patient. 
Infection often takes place from the carpets or furniture of the Bick-room, 
and from the clothing of the patient. In a city the bed-clothing, while 
airing in the window, has been known to convey the disease to ;m adjoin- 
ing house. Instances are recorded of the spread of scarlet fever by the 
washing of infected wi tli other clothing. Toys or booka may be carriers 
of the disease. A bouquet of flowers senl from a Bick-room to an institu- 
tion, in one instance proved a vehicle of infection. Cats dogs, and other 
domestic animals are known to have conveyed the disease. Scarlel fever 
is sometimes spread by food, particularly by milk, as in the well-known 
epidemics of Hendon and Wimbledon (England). It is possible, under 

*Part of these are from personal observation, but the great majority are isolated 
cases scattered through medical literature, occurring under circumstances *hich mads 

it possible to determine the exact lengl b of incubal km. 



890 THE SPECIFIC INFECTIOUS DISEASES. 

these circumstances, that a disease resembling scarlatina existed in the 
cows ; but that this was identical with scarlet fever, as seen in man, was 
not demonstrated. 

The transmission of the disease through a third party is not frequent, 
but numerous instances of it are on record. The persons most likely to 
carry it are the nurse and the physician. Physicians have in many cases 
carried scarlatina to their own children, but only when there had been 
pretty direct contact with the patient, and where the interval before seeing 
the second child was short. The clothing of the nurse may be almost as 
infectious as that of the patient. The transmission of the disease by one 
who, although living in the house, does not come in contact with the 
patient is extremely improbable. I can find no instance recorded where 
scarlatina has been transmitted through two healthy persons. 

Duration of the infective period. — There is no evidence to show that 
the disease is communicable during the period of incubation. It, how- 
ever, becomes so from the beginning of invasion, even before the rash 
appears. Infection is doubtless most active during the febrile period — 
from the second to the fifth day — and, next to this, during the stage of 
active desquamation. 

In simple cases, the average duration of the contagious period may be 
placed at six weeks, or until desquamation is complete. However, physi- 
cians generally have been accustomed to place too much stress upon the 
danger from the scales, and too little upon that from the discharges from 
the mucous membranes. Early infection comes chiefly from the throat, 
nose, or possibly the breath. Late infection may arise from a purulent 
otitis, rhinitis, chronic pharyngitis, suppurating glands, eczema, empyema, 
and possibly also from the urine in nephritis. The infectious nature of 
these purulent discharges has not been sufficiently recognised. It is pos- 
sible for them to convey the disease during a period of several months. 
One case is recorded in which scarlatina was communicated through a 
purulent nasal discharge after eleven weeks ; another in which the open- 
ing of a post-scarlatinal empyema in a surgical ward was followed by an 
outbreak of scarlet fever. 

In winter especially, a chronic pharyngeal catarrh may long contain 
the germs of infection. Ashby found, on careful investigation, that from 
two to four per cent of patients discharged from a scarlet-fever hospital 
subsequently conveyed the disease. There is particular danger from a 
child who has recently had the disease, sleeping with other children. 
Line records a case in which this was the means of conveying the disease 
after fourteen weeks, and when the patient had been considered perfectly 
well for three weeks. It is impossible to say that at any specified time 
absolute safety exists. All patients before being discharged from a hospi- 
tal or released from quarantine in private practice, should be carefully 
examined as to the condition of the mucous membranes, and quarantine 



SCARLET FEVER. 891 

continued as long as catarrhal inflammations are present. The poison of 
scarlatina clings more tenaciously to clothing, upholstery, and apartments 
than that of any other contagious disease, possibly excepting tuberculosis. 
Authentic cases are on record in which more than a year had elapsed 
between the first and second cases, "where the source of infection seemed 
certain. 

Lesions. — The only essential lesions of scarlet fever are those of the 
skin and the mucous membrane of the throat. The other changes occur- 
ring in this disease are considered in the light of Complications, under 
which head they are described. 

The earliest changes in the skin consist in an intense hyperemia with 
dilatation of all the small blood-vessels; following this, there is an exu- 
dation of round cells into the rete Malpighii, and considerable swelling, 
due partly to the exudation of cells and partly to oedema. There are also 
thickening of the lining membrane of the sweat ducts, and infiltration 
about these ducts with round cells. In some cases there is destruction 
of the epithelium lining the sweat ducts, and the lumen of the duct is 
filled with granular detritus, occasionally with blood. The local process 
results in death of the epidermis, which is cast off during desquamation. 
It is essentially an acute dermatitis, which varies in intensity with the 
severity of the attack. The only constant lesion in the throat is an ery- 
thematous pharyngitis, with the usual changes of a catarrhal inflammation. 

Symptoms. — Invasion. — As a rule, the invasion of scarlet fever is ab- 
rupt, the symptoms at the onset usually being directly in proportion to 
the severity of the attack. In the majority of cases there are vomiting, ;i 
rapid rise in temperature, and soreness of the throat. Often the vomiting 
is repeated ; it is frequently forcible, and without nausea. h\ severe cases 
the rise in temperature is very rapid, to 104° or 105° F. ; in the mildest 
cases it may not be above 101°. A child may complain of soreness of 
throat, or the throat symptoms may be entirely objective, hi most severe 
cases, there is a uniform erythematous blush covering the pharynx, tonsils, 
and fauces, but on the hard palate consisting of minute red points. The 
appearance of this is usually coincident with the rise in temperature. 
Occasionally membranous patches maybe seen upon the tonsils the first 
day, but not generally before the third or fourth day In mild cases the 
throat shows only a very moderate congestion, and in Borne presents noth- 
ing abnormal. Severe cases an- sometimes ushered in by convulsions, 
especially in very young children. Diarrhoea is nol uncommon in Bum- 
mer. There is general prostration, which is directly proportionate to the 
height of the fever. 

Eruption.— This nsually appears from twelve to thirty-six hours after 
the first symptoms of invasion ; exceptionally, nol until the third or even 
the fifth day. A later appearance than this is Boraewhal doubtful) for the 
rash not infrequently recedes and reappears, having been overlooked in 



892 THE SPECIFIC INFECTIOUS DISEASES. 

the first instance. In 108 cases observed in the New York Infant Asylum, 
the duration of the rash was as follows : 

Two days or less 5 cases. 

Three to seven days 81 " 

Eight to eleven days 16 " 

Over eleven days 4 " 

Recurring 2 " 

These statistics are confirmed by the observations of most writers, that 
the rash lasts from three to seven days. The full development of the rash 
is generally seen in from twelve to twenty-four hours from its first appear- 
ance, and not infrequently the whole body is covered in the course of 
four or five hours. Very rarely its extension is so slow that it is two or 
three days before the body is covered. Its first appearance is almost in- 
variably upon the neck and chest. Where the rash is faint, it is some- 
times earliest and most intense over the sacrum, buttocks, and back of 
the thighs. In the cases of moderate severity the typical rash is seen. It 
is of a bright scarlet colour, and on close inspection is seen to be made 
up of very minute points ; it covers the entire body, including the face. 
There is often a peculiar pallor about the mouth, in striking contrast with 
the rest of the face, which is quite characteristic of the disease. 

Variations in the eruption are very frequent, and often extremely puz- 
zling. In the mild cases the rash is not seen upon the face ; it is often 
faint upon the body, and may be present only upon certain parts ; it may 
last only one day, and sometimes may be so slight as to escape notice 
altogether. It may be absent in some very mild cases, in certain others 
where the throat symptoms are severe, and in malignant cases. In the 
very severe cases many irregularities are seen, both as to the time of the 
appearance of the eruption and its character. Sometimes it occurs as 
large, irregular patches; at others it is macular, closely resembling the 
rash of measles ; occasionally it is of a dark purplish colour ; and very 
rarely it is hemorrhagic. An eruption of fine miliary vesicles has been 
observed in connection with a fully-developed rash. Much importance is 
attached by the laity to the early disappearance of the rash, an especial 
danger being believed to exist because the disease has "struck in." A 
well-developed bright scarlet rash indicates strong heart action, and a 
sudden recession of the rash is a sign of heart failure. Often a rash which 
is faint and doubtful in character, may be brought out fully by a hot bath. 

With the eruption at its height, there is intense itching or burning of 
the skin, and in severe cases considerable swelling, chiefly noticeable upon 
the hands and face. All the constitutional symptoms increase in intensity 
as the rash develops, and usually diminish gradually as it fades. 

Desquamation. — Shortly after the rash has faded there is an exfolia- 
tion of the dead epidermis, known as desquamation. This is even more 
characteristic of the disease than the rash. It is usually first seen upon 



SCARLET FEVER. 



893 



the neck and chest, where it appears as fine scales or small patches. 
The desquamation of the trunk is completed in from one to three weeks. 
If baths and inunctions are being used, it is scarcely perceptible. It 
continues longest where the epidermis is thickest — viz., upon the hands 
and feet — and here it lasts from three to six weeks, and not infrequently 
eight weeks. The appearance of the fingers and toes during desquama- 
tion is characteristic. The finger tips usually peel first, and the new 
epidermis is pink and fresh-looking, while that which has not yet sepa- 
rated is of dull gray colour and loosened at the margin. Occasionally the 
epidermis of a considerable part of a finger may be loosened at once, so 
that a partial cast may be thrown off like the finger of a glove. Some- 
times the patient comes under observation for the first^ time during des- 
quamation, the history of the early 
symptoms being doubtful or ab- 
sent. Such desquamation as has 
been described, occurring both 
upon the hands and feet, may be 
regarded as conclusive evidence 
of scarlet fever, no matter what 
the history may be. 

1. The mild cases. — The symp- 
toms may be so slight as to be 
entirely overlooked, nothing be- 
ing noticed until desquamation 
occurs. Usually, however, there 
is a rather abrupt invasion, with 
vomiting and a temperature of 
100° to 103° F. The tonsils and 
pharynx are congested, while the 
palate shows a punctate redness 
somewhat like the cutaneous 
eruption. Xearly always within 

twenty-four hours the rash makes its appearance, generally first upon the 
neck and chest. Very often it is not seen upon the face, but the reel of 
the bodv is usually covered. The rash fades on the third or fourth day, 
and has disappeared by the fifth day. There is very little prostration, the 
child often being with difficulty kept in bed. 

The highest temperature is coincident with the full eruption, and is 
seen during the first thirty-six hours of the disease. It gradually fa] 
normal by the fourth or fifth day. Its typical course is shown in 
154. In the mildest cases the temperature may never he ah-. v.' L00° P., 
and the rash may last but one day, and even then may come OUl • 
imperfectly and over only a portion of the body— the chesl or the loins. 

Desquamation is often faint over the body, but is unmistakable over 



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Fig. 154 — Typical temperature curve of mild 
let fever; uncomplicated; id ■ child three 
years old. 



894 



THE SPECIFIC INFECTIOUS DISEASES. 



the hands and feet. It begins about the end of the first week, always 
being most marked where the eruption has been most intense. 

The mild cases are usually uncomplicated, but the possibility of otitis 
and of late nephritis should always be kept in mind, as these may occur 
even with the mildest attacks. The difficulties in diagnosis in mild at- 
tacks of scarlet fever are often great. It should be remembered that these 
cases are just as contagious as severe ones, and that from a mild attack a 
severe one is often contracted. It is frequently by these mild cases that 
this disease is spread in schools. In dispensaries I have often seen pa- 
tients desquamating from scarlet fever, who had been attending school 
regularly up to the time when they were brought for treatment for ne- 
phritis or some other disease. 

2. Cases of moderate severity. — The onset is sudden with vomiting, 
which is usually repeated, or with convulsions. The temperature rises 



105° 



103° 
102° 
101° 

100° 



I 



n 



i 



§ 



m 



n 



u 



E 



m 



^^ 



Fig. 155. 



-Moderately severe scarlet fever, running a prolonged course, but without complica- 
tions ; the patient, a boy two and a half years old. 



rapidly, and by the end of the first twenty-four hours has reached 104° or 
105° F. The rash usually appears within the first twenty-four hours, and 
its intensity is directly proportionate to the severity of the attack. Ap- 
pearing first upon the neck or chest, it extends rapidly, covering the entire 
trunk, extremities, and often the face in a few hours. It is usually typical 
in appearance, being made up of minute points, but giving the appearance 
of a uniform blush, which has been compared to a boiled lobster. Little 
change takes place in the rash for four or five days. After this it fades 
quite rapidly, and disappears by the seventh or eighth day. 

The throat resembles that of the mild form, except that the redness is 
more intense and there is slight swelling of the tonsils, fauces, and uvula, 



SCARLET FEVER. 895 

and often pain upon swallowing. Occasionally small yellowish patches are 
seen upon the tonsils by the second or third day, but these can be wiped 
off and are not distinctly membranous. There is usually a moderate 
discharge of a sero-purulent character from the nose. The lymphatic 
glands at the angle of the jaw are swollen and quite tender. The tongue 
shows first a white, frosty coating, and after a few days may clear at the 
border. The intense redness at the tip and margin of the tongue, with 
the enlarged papillae, gives rise to what is known as the " strawberry 
tongue," which, though not peculiar to scarlet fever, is a very frequent 
symptom. 

During the height of the fever there are restlessness, thirst, and not 
infrequently slight delirium. The temperature reaches the maximum by 
the second or third day, and usually falls gradually after the fourth or 
fifth day, but even in uncomplicated cases the fever often lasts from ten 
to fourteen days (Fig. 155). The pulse in the early part of the disease is 
rapid and full, but later it may be weak. There is much prostration, fre- 
quently followed by quite a marked degree of anaemia. 

This form of the disease rarely proves fatal apart from complications, 
but it may do so in very young infants. The complications seen most 
frequently in this form of scarlet fever are broncho-pneumonia or pleuro- 
pneumonia and otitis, the latter being usually double and occurring be- 
tween the sixth and the fourteenth days. Nephritis is the only common 
sequel. 

3. The severe cases. — The severe type of scarlet fever usually declares 
itself from the beginning. The incubation is short, and the full rash may 
be seen within a few hours after the initial symptoms. It covers the en- 
tire body, including the face. The severity of the infection is shown by 
the fact that the temperature is higher and continues for a longer period, 
and by the frequency and severity of the complications, particularly those 
of the throat. For the first two days the throat presents Dothing different 
from what is seen in the milder cases. By the third or fourth day, how- 
ever, membranous patches often appear on the tonsils, and spread to the 
soft palate, uvula, and pharynx, sometimes to the Dose and throughthe 
Eustachian tube to the ear, rarely to the larynx. The mucous mem- 
brane of the mouth is intensely congested, and often partly covered by 
membrane; there is sordes on tie- Lips and fceeth, and there may be super- 
ficial ulcers, which ble.-d readily. The glands of the peck swell rapidly, 
often to a great size, and the cellular tissue about them is infiltrated. The 
head is thrown back to relieve the dyspnoea which the pressure from this 
swelling occasions. There is an abundant discharge from the aose and 
mouth; the breath is offensive, of ten fetid. The general symptoms are 
those of a severe septicemia. The temperature is steadily high, usually 
between 103° and 105° F., the fluctuations being usually narrow for the 
first week or ten days. In ctfses which recover, the subsequent oour 



896 



THE SPECIFIC INFECTIOUS DISEASES. 



greatly modified by the presence of complications (Fig. 156). The fever 
generally lasts from three to four weeks. In fatal cases the temperature 
may be steadily high till death (Fig. 157), or may fluctuate widely. The 
pulse is rapid, weak, and irregular. There is complete anorexia ; both 
food and stimulants have to be coaxed or forced down. There is low 
delirium or apathy, and sometimes all the symptoms of the typhoid con- 
dition are present. 

Signs of a broncho-pneumonia are found in the chest, and by the end 
of the first week or early in the second the ears begin to discharge. The 
urine is rarely free from albumin, but the amount present is not usually 
great; there may be hyaline and epithelial casts, and often blood. In 
some cases the throat symptoms predominate ; in others, those of general 
sepsis, but more frequently the two are combined and are directly propor- 
tionate to each other. In still other cases, instead of the membranous in- 
flammation, it may be of a gangrenous character, and extensive sloughing 
may take place in the throat, and even in the cellular tissue of the neck. 

The duration of the symptoms in fatal cases is from six to fourteen 
days. There are generally increasing prostration and finally a septic 
stupor, with death from exhaustion, from sudden heart failure, or from 
some of the complications, — broncho-pneumonia, pleurisy, nephritis, haem- 
orrhages following sloughing, laryngitis, pericarditis, or endocarditis. In 
cases which recover, the acute symptoms nearly always continue for a full 



n 



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m 



i 



e 






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t 



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ft 



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Fig. 156. — Severe scarlet fever complicated by double otitis and nephritis; primary fever pro- 
longed ; otitis began on the thirteenth day ; nephritis on the nineteenth day ; recovery ; the 
patient a girl twenty months old. 

month ; and after escaping the dangers of sepsis and the early complica- 
tions, the child has still to run the gantlet of all the late complications — 
nephritis, pneumonia, endocarditis, pyaemia, etc. A case may prove fatal 



SCARLET FEVER. 



897 



as late as the end of the seventh week ; nearly all such results are due to 
nephritis or to its complications. 

4. Malignant or cerebral cases. — These are rare cases which are more 
frequently described than seen, 
and in which death takes place 
usually within the first forty- 
eight hours. The system is over- 
powered by the scarlatinal poison. 
Such cases are seen only in severe 
epidemics. Under other circum- 
stances, many cases of unexpect- 
ed death with high temperature 
are diagnosticated maligna at 
scarlet fever which have no con- 
nection with this disease. 

The onset is sudden and vio- 
lent, usually with convulsions, 
the child passing in a few hours 
into a condition of deep stupor, 
with great prostration and hyper- 
pyrexia, the temperature ranging 
from 105° to 107° F. The rash 
appears irregularly, late, or not 
at all. There are frequently re- 
peated convulsions, cyanosis, and 
invariably a fatal termination. 
The autopsy often gives no satis- 
factory explanation of these cases. Death occurs from toxaemia, without 
any characteristic local evidences of disease. 

5. Surgical scarlet fever. — Patients with recent wounds, or those who 
have been subjected to surgical operations, are peculiarly susceptible to the 
scarlatinal poison, and are almost certain to contract the disease upon ex- 
posure, unless protected by a previous attack. Whetherthe infection takes 
place directly through the wound, or whether the susceptibility depends 
upon the diminished resistance of the patient, is still an open question. 
This disease doubtless explains some of tin- unexpected deaths occurring 
after minor surgical operations. Scarlet fever may occur after any opera- 
tion, even one so trivial as tenotomy or circumcision. Patients with 
burns are generally believed to be especially susceptible. The effect «>f 
scarlet fever upon the wound, and Borne of its peculiar clinical features, 
are illustrated by the following oases from Walton Browne ( Belfast) : 

A healthy child was operated upon for hare-lip; Bixteen bours after- 
ward it became seriously ill, the skin was covered with a dark scarlatinal 
rash, and death quickly followed. Another patient who, it was afterward 
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Fig. 157. — Severe scarlet fever, septic type ; double 
otitis, severe membranous angina; death on 
the ninth day; the patient a girl Beven yean 

old. 



898 THE SPECIFIC INFECTIOUS DISEASES. 

learned, had been recently exposed directly to scarlatina, was circumcised 
for congenital phimosis. In thirty hours he was covered with a scarla- 
tinal rash and had a temperature of L04° F. In forty hours the wound 
became gangrenous and the patient passed into a condition of coma, in 
which he died in seventy hours. A child admitted to the hospital with a 
lacerated wound of the leg was accidentally placed in a bed next to one 
in which was a patient who had just developed scarlatina. The exposure 
lasted less than an hour, but in six hours the child was taken with vom- 
iting, high fever and headache, became rapidly comatose, and died in 
fifteen hours, no rash having appeared. After death, however, a purpuric 
rash could be seen upon the skin. 

Surgical scarlatina is nearly always irregular in its symptoms; the 
incubation is very short, the rash usually atypical, and the general symp- 
toms, particularly those relating to the nervous system, especially severe. 
There may or may not be throat symptoms. It should be said that many 
writers deny that surgical scarlet fever is anything more than septicaemia 
with an erythematous rash. This is undoubtedly true of some of those 
reported as surgical scarlet fever ; but it certainly is not the explanation 
of all. That some of these are cases of genuine scarlet fever is shown by 
the fact that they have been known to communicate the disease, and that 
they are often followed by nephritis and usually by desquamation, although 
the latter is not invariable. But in the absence of throat symptoms, des- 
quamation, and contagion, the diagnosis of scarlatina should be made with 
extreme caution. Care should be taken to exclude erythematous eruptions 
due to the various antiseptics used in surgical dressings. 

Relapses, Recurrences, and Second Attacks. — As a rule, one attack of 
scarlatina gives immunity through life. The exceptions are very few, but 
some of them are well authenticated. Kinnicutt (New York) observed 
two attacks within eight months in a boy of five years ; Pritchard (Glas- 
gow) reports the case of a patient who had three attacks in the same 
hospital within two years ; such cases are certainly extremely rare. 

Relapses or recurrences within a brief period after the first attack are 
most frequent. There are to be excluded the cases of pseudo-relapses in 
which the rash, having temporarily subsided for two or three days, reap- 
pears ; also those where the rash varies in intensity from time to time ; 
and, lastly, the cases in which, occurring late in the disease, it is due to 
septicaemia or pyaemia. True relapses are usually due to auto-infection, 
sometimes to a new accession of poison from without. They are analo- 
gous to the relapses of typhoid fever. They occur most frequently during 
desquamation, between the seventh and twenty-fourth days. There may 
be not only a new eruption but a rise of temperature, sore throat, and 
vomiting, just as in the initial attack. These recurrences are sometimes 
shorter and milder than the first attack, but this is by no means uniform, 
since Koerner mentions eight cases where the second attack proved fatal. 



SCARLET FEVER. S99 

In considering the subject of second attacks, the liability to errors in 
diagnosis must be borne in mind and only cases included which have pre- 
sented typical symptoms. 

Complications and Sequelae. — Throat. — Three distinct forms of angina 
are seen in scarlatina : simple or erythematous, membranous, and gan- 
grenous. 

1. Erythematous angina. — This can hardly be ranked as a complica- 
tion, as it is nearly as constant as the scarlatinal rash. Usually there is 
only the general blush over the entire pharynx with the fine red points 
upon the hard palate ; but there may be seen upon the tonsils grayish- 
yellow spots resembling those of follicular tonsillitis, which can be wiped 
off, leaving a clean surface. This simple angina is at its height with the 
maximum temperature, and fades as the temperature falls. It does not 
often extend to adjacent mucous membranes. 

2. Membranous angina. — These cases were formerly classed as scarla- 
tinal diphtheria, and whether this process was identical with primary 
diphtheria or not, was for a long time a subject of much discussion. This 
question has, however, been settled by bacteriology. It is now generally 
agreed that the membranous angina which occurs early in scarlet fever, 
and that which develops at the height of the disease, are almost invari- 
ably due to the streptococcus, the diphtheria bacillus being rarely found ; 
but that the cases which develop late in the disease, and after the primary 
fever has subsided, are almost invariably true diphtheria, the bacillus being 
regularly present. The latter condition is to be regarded as scarlet fever 
complicated by diphtheria. 

The lesions of this form of angina are considered in the chapter on 
Pseudo-Diphtheria. Usually on the second or third day of the disease fche 
membrane appears upon the tonsils, and in the milder cases it covers 
only the tonsils. In the most severe form it may be seen within twenty- 
four hours of the onset, frequently before the eruption appeals. Be- 
ginning upon the tonsils, the membrane rapidly spreads to the entire 
pharynx, the mucous membrane of the nose, the mouth, the Eustachian 
tube, and even the middle ear. In colour it may be gray, greenish, or almost 
black. There is so much swelling of the throat that Bwallowing becomes 
difficult. The infiltration of the cellular tissue of the neck and theenlarged 
lymphatic glands produce great external swelling, which may extend like 
a collar from ear to ear. The breath has a foul odour, the nasal disci 
is thin and fetid, and nasal respiration i< obstructed, so that the mouth 
is open constantly. Occasionally the larynx is invaded, with tie- usual 
symptoms of membranous croup. 

These local changes arc accompanied by constitutional symptoms <<f 
great severity, which are due to a general streptococcus Bepticamia; 
broncho-pneumonia and nephritis are very frequent, otitis is almost 
stant, and suppuration of the lymphatic gland- is ool uncommon. 



900 THE SPECIFIC INFECTIOUS DISEASES. 

As the eruption in these cases is late and often very irregular in ap- 
pearance, the diagnosis from true diphtheria is often a matter of great 
difficulty, and a positive diagnosis is possible only by making cultures 
from the throat. 

3. Gangrenous angina. — This is seen only in the worst cases of scarlet 
fever. The process may be gangrenous from the outset, or preceded by a 
membranous inflammation. It is sometimes insidious in its development. 
There is a fetid odour to the breath, irritating discharges from the nose 
and mouth, with very great glandular swelling. The tonsils are gray or 
grayish-black in colour, and large masses of necrotic tissue may be re- 
moved with the forceps from the tonsils, uvula, fauces, or pharynx, and 
sometimes sloughing occurs in the cellular tissue of the neck. Blood- 
vessels of considerable size are often opened, and serious, or even fatal 
haemorrhage may result. Little or no tendency to a reparative process is 
seen. The constitutional symptoms are those of great asthenia, prostration, 
and profound cachexia, followed almost invariably by a fatal termination. 

Lymph nodes. — These are swollen in all cases accompanied by severe 
angina. The inflammation may be simply an acute hyperplasia, or it may 
go on to suppuration. Abscess does not often occur at the height of the 
disease, but may come at any time during convalescence. It may be con- 
fined to the glands or be complicated by suppuration in the cellular tissue 
of the neck. Disease of these glands is not an infrequent cause of torti- 
collis. 

Cellulitis of the neck. — This usually occurs toward the end of the first 
week, and is associated with grave throat symptoms. Rapid and extensive 
infiltration occurs, the skin becomes tense and brawny, the head is held 
back, and there may be considerable dyspnoea. The infiltration may be 
only in the neighbourhood of the lymphatic glands or it may be diffuse. 
Unless relieved by early incision, the diffuse form may result in suppuration 
and extensive sloughing, which may be deep enough to lay bare the large 
vessels of the neck. This is a complication of the gravest possible im- 
port. Death may occur from septicaemia before or after sloughing or 
from haemorrhage due to opening by ulceration of the external carotid or 
some of its branches; or there may be associated thrombosis of the jugu- 
lar vein, leading to thrombosis of the lateral sinus, meningitis, or pyaemia. 

Ears. — The otitis is due to direct extension of the infection from the 
rhino-pharynx. It is the most frequent complication of scarlatina, and in 
doubtful cases may have some diagnostic importance. As a rule, the 
younger the child the greater the liability to otitis. It is more frequent 
in winter than at other seasons. Like all complications, it varies greatly 
with the epidemic, and is closely connected with the severity of the throat 
symptoms. In an epidemic occurring in the New York Infant Asylum 
in the spring and summer of 1889 there were 73 cases of scarlatina and 
not one of otitis. In a fall and winter epidemic in the same institution 



SCARLET FEVER. 901 

two years later, of 43 cases 20 per cent had otitis. Of 4,397 cases re- 
ported by Finlayson, otitis occurred in 10 per cent, and of 1,008 cases 
reported by Caiger, in 13 per cent. In Burkhardt's statistics the propor- 
tion was as high as 33 per cent. Of cases accompanied by severe throat 
symptoms otitis is present in fully 75 per cent. 

As a rule, both ears are affected, but not simultaneously, or at least 
rupture occurs at different times. This is most frequent early in the sec- 
ond week, but may occur during convalescence. In the cases where otitis 
develops at the height of the disease there are in some cases no new symp- 
toms ; in others there are pain and deafness. If it develops at a later 
period there is usually a rise in the temperature, which falls after rupture 
of the drum membrane takes place. The otitis is sometimes overlooked 
until symptoms of pyaemia or meningitis develop. The form of inflam- 
mation may be catarrhal or suppurative (page 880), the latter being often 
accompanied by necrotic changes. 

Bezold makes the following report upon 185 cases showing the results 
of scarlatinal otitis : " In 30 there was entire destruction of the membrana 
tympani, with loss of one or more bones ; in 59 the perforation comprised 
two thirds or more of the membrane ; in 13 there were smaller perfora- 
tions ; in 44 there were granulations or polypi ; in 15 there was total loss 
of hearing on one side, and in 6 of the cases upon both sides ; in 77 of 
the cases the hearing distance for low voice was less than twenty inches." 

As a cause of permanent deafness and deaf-mutism, no disease of child- 
hood compares in importance with scarlet fever. May (New York) has 
collected statistics of 5,613 deaf-mutes, of whom 572 owed their condition 
to otitis following scarlet fever. 

Kidneys. — Albuminuria accompanies nearly all the severe cases of 
scarlet fever. In many this is simply the ordinary febrile albuminuria 
due to acute degeneration of the kidneys (page 612). In those with 
severe throat complications, and in nearly all the septic cases, there ifl an 
acute inflammation of the kidney, usually of the variety described as acute 
exudative nephritis (page 613). This occurs at the height of the febrile 
process and is rarely accompanied by dropsy ; but albumin, casts, and even 
blood may be found in the urine. The most severe ami the most charac- 
teristic renal complication, and that generally designated as postscarla- 
tinal nephritis, is a diffuse nephritis which in most cases develops during 
the third week of the disease. It is accompanied by general dropsy; the 
urine is scanty and not infrequently suppressed, and it contains a large 
amount of albumin and great numbers of casta of all varieties. It may 
cause death by the occurrence of acute nr»mia, <>r it may 1"' followed by 
permanent damage to the kidneys. It is more fully described with tic 
Diseases of the Kidney (page 615). 

Joints. — Acute articular rheumatism may occur coincidently with the 
development of the scarlatinal rash, and occasionally during convalescence 



902 THE SPECIFIC INFECTIOUS DISEASES. 

in patients who have a predisposition to that disease. Acute swelling of 
the joints is sometimes of pysemic origin. A case is reported by Henoch 
in which this was due to an infectious thrombus in the jugular vein, asso- 
ciated with cellulitis of the neck. In pyaemic arthritis the large joints are 
usually involved and the lesions are apt to be multiple. Joint disease 
may occur as a sequel of scarlet fever, where it is secondary to disease of 
the bone or to periarticular abscesses opening into the joint. 

The foregoing include but a small proportion of the joint complica- 
tions seen in scarlet fever. The most frequent and most characteristic 
form of inflammation is scarlatinal synovitis, or, as it is sometimes called, 
scarlatinal rheumatism. It occurs in different epidemics with varying 
frequency. Oarslaw (Glasgow) in 533 cases of scarlet fever met with syno- 
vitis in 60 patients. It is seldom seen in children under three years of age, 
and is most frequent after five years. It may occur in mild as well as 
in severe cases. According to Ashby, it is more frequent when the febrile 
stage is prolonged, owing to other complications. Synovitis develops quite 
uniformly toward the end of the first or the beginning of the second 
week. The symptoms are generally mild, and are followed by prompt 
recovery. Suppuration is rare. Any of the joints may be attacked, but 
those of the wrist and hand are most frequently and often the only ones 
affected. Demme (Berne) has reported a case in which every large joint 
in the body was involved. The symptoms are redness, moderate pain, 
swelling, which is usually due to synovial distention, and sometimes a 
slight rise of temperature. The duration is generally but three or four 
days, and in most cases there is spontaneous recovery. This disease, is dis- 
tinguished from rheumatism by several points : it is not more frequent 
in rheumatic patients; cardiac complications are rare as compared with 
those seen in patients with genuine rheumatism ; in some epidemics it is 
very common, and in others seldom seen ;, there is little or no tendency 
to relapses ; anti-rheumatic remedies are without striking benefit ; it does 
not skip about from joint to joint, and usually fewer joints are in- 
volved. 

Lungs. — The pulmonary complications of scarlet fever are neither so 
frequent nor so important as those of measles. Broncho-pneumonia is 
usually found at autopsy in septic cases where death has occurred later 
than the third or fourth day, but it is not generally recognisable by phys- 
ical signs. 

In septic cases pleuro-pneumonia sometimes occurs early in the disease 
and at other times late, generally associated with nephritis, but occasion- 
ally without it. It is always a serious condition and not infrequently a 
direct cause of death. Empyema may follow pleuro-pneumonia or occur 
with pyasmia or nephritis, but with the latter, simple serous pleurisy is 
more common. (Edema of the lungs occurs chiefly with nephritis, in 
which it is the most common cause of death. 



SCARLET FEVER. 903 

Heart. — Abnormal cardiac sounds, not dependent upon organic lesions, 
are frequent during the height of the disease. Endocarditis and pericar- 
ditis are not common. They are occasionally seen in septic cases and in 
those complicated by pyaemia, but principally as a complication of post- 
scarlatinal nephritis or in rheumatic patients. Endocarditis may be 
simple or malignant, and may be the cause of embolism and hemiplegia 
during convalescence. 

A certain degree of degenerative change in the cardiac muscle is found 
in nearly every fatal case that has lasted over four days. More marked 
evidence of toxic myocarditis is not infrequent in the prolonged cases and 
in those of a septic type. This may be followed by acute dilatation of the 
left ventricle or of the entire heart, and it may be a cause of sudden death. 

Digestive system. — Functional disturbances are very frequent, and, in 
fact, are seen in most of the cases, but organic changes are rare. Vomit- 
ing is the. mode of onset in the majority of cases, but rarely continues 
through the attack. Late in the disease it is a frequent symptom of urae- 
mia. Diarrhoea may be associated with it under both conditions. The 
tongue is nearly always coated, and clears off in quite a characteristic way, 
which, with the prominent papillae, gives rise to the strawberry appear- 
ance. Catarrhal stomatitis is a very frequent complication, and in many 
cases of severe membranous angina, the same process is seen in the buccal 
cavity. 

Nervous system. — Nervous complications and sequelae are seen less 
frequently with scarlatina than with most of the infectious diseases of 
such severity. Convulsions are frequent at the outset, and generally in- 
dicate a severe attack, though not invariably so. Occurring late in the 
disease, they are usually due to uraemia, and may be a cause of death. 
Meningitis may occur as a complication of otitis, in pyoemic cases, and 
sometimes with post-scarlatinal nephritis. Paralysis from peripheral 
neuritis is rarely seen. Hemiplegia sometimes occurs from meningeal 
haemorrhage, or from embolism secondary to endocarditis and associated 
with nephritis. Chorea was noted as a sequel in only three of 533 casi e 
reported by Carlslaw. In a report of 187 cases of epilepsy, Wildermuth 
states that it followed scarlet fever in 12 cases. Insanity baa been occa- 
sionally observed, the usual form being acute mania, with complete n 
ery in a few weeks or months. 

Gangrene. — Cases of symmetrical gangrene after scarlet fever have 
been reported by Wilson and others. The parts generally affected are 
the buttocks, thighs, and anus, but it may occur almost anywhere. The 
pathology of these cases is obscure. The process usually begins in 
eral places simultaneously, or in rapid succession, and advances steadily 
till death occurs. 

Other infectious diseases.— -Scarlet fever is not, very infrequently com- 
plicated by other forms of infectious disease. It is Been with diphtheria, 



904 THE SPECIFIC INFECTIOUS DISEASES. 

measles, varicella, erysipelas, and occasionally with variola and typhoid 
fever. The symptoms are an irregular commingling of those belonging 
to the two diseases. They may begin simultaneously, or more frequently 
one develops as the other is subsiding. 

Diagnosis. — The characteristic symptoms of scarlet fever are the abrupt 
onset, usually with vomiting, the marked elevation of temperature, the 
erythematous condition of the throat, and the appearance of the rash 
within twenty-four hours. Before the eruption it can not be diagnosti- 
cated from tonsillitis or many other diseases. The difficulties of diagnosis 
usually depend upon irregularities in the eruption, both as to the time of 
its appearance and its character. These variations are seen in the mild- 
est, and in the most severe cases. In the former the temperature may 
not be above 100'5° F., the rash may last less than a day, and may be seen 
only upon the chest and neck, or there and upon the loins, but very often 
it does not cover the trunk and extremities. Nothing is positively diag- 
nostic about these symptoms, even when associated with some degree of 
redness of the throat, which is by no means constant. But the appearance 
after them of desquamation is usually conclusive. In some cases, how- 
ever, this is of so uncertain a character that, even after the entire course 
of the disease, the diagnosis may remain in doubt. A history of an un- 
doubted exposure within a week prior to the onset, or the fact that othe,r 
cases of scarlet fever subsequently develop in the family or hospital, great- 
ly strengthens the diagnosis. 

Cases of malignant scarlet fever which prove fatal before a character- 
istic eruption appears, can not be diagnosticated with certainty ; but when 
such cases are preceded or followed by others of a typical character, the 
diagnosis can be made with a strong degree of probability. 

The form of the disease in which the throat symptoms are of great 
severity and appear early, are often difficult to distinguish from true diph- 
theria. Here the only reliable ground of distinction is that afforded by 
the bacteriological examination. There are, however, points in the local 
appearances which are of some assistance in the absence of the culture 
test. These are discussed in connection with the Diagnosis of Diphtheria. 

The eruption of scarlet fever may be confounded with that of measles, 
rubella, urticaria, and various forms of erythema. The typical eruption 
of measles has little that suggests scarlet fever, appearing as it does first 
upon the face and spreading slowly over the body ; but in irregular cases 
the eruption may resemble neither disease. The diagnosis must then rest 
upon the other symptoms : the sudden onset with vomiting in scarlet 
fever, or the gradual onset with marked catarrhal symptoms in measles. 
The eruption of rubella is more difficult to distinguish. In this disease 
the important thing is that, although the rash may be well marked, often 
covering the body, the constitutional symptoms are few or entirely ab- 
sent. In scarlet fever with an eruption of the same intensity there is in- 



SCARLET FEVER. 905 

variably a considerable elevation of temperature, usually 102° to 103° F., 
and a bright red throat. 

There are so many skin eruptions which may resemble that of scarlet 
fever, that it is always hazardous to make the diagnosis of this disease 
from the eruption alone. This is especially true of sporadic cases occur- 
ring in infants; there is seen at this age a great variety of eruptions, 
usually associated with digestive disturbances, which closely simulate a 
scarlatinal rash ; but most of them are of short duration. A scarlatini- 
form erythema is occasionally seen in diphtheria, influenza, typhoid fever, 
and varicella, which may cause them to be mistaken for scarlet fever, or 
may lead to the diagnosis that both diseases are present. The same is 
the case with the septic erythema occurring in surgical patients. Bella- 
donna, quinine, and occasionally antipyrine, may produce eruptions more 
or less closely resembling that of scarlet fever. This is also true of some 
cases of urticaria, and of several other forms of skin disease. There is 
little doubt that many of the cases reported as relapsing scarlatina are 
really examples of recurring erythema, particularly as some of the latter 
are followed by a desquamation which is very similar to that after scar- 
latina. In all doubtful conditions great importance is to be attached to 
the constitutional eruptions. 

Prognosis. — The mortality of scarlet fever varies much in different 
epidemics. In some, nearly all the cases are of a mild type, and the 
mortality maybe as low as 3 or 4 per cent; in others, a severe or malig- 
nant type prevails, and it may be as high as 40 per cent. The disease is, 
as a rule, more fatal in the youngest infants, becoming less so as age ad- 
vances. This is well shown in two recent epidemics in the New York 
Infant Asylum. There were— 

Under one year 29 cases; mortality. 55 per cent. 

From one to two years 37 

« two " three " 28 " 7 « 

Over three years 23 " 

In the first epidemic the general mortality was L2*5 percent ; in the 

second it was 33 per cent, in the same class of children. 

The following are the mortality records from various European 
sources : 

Ashby, Manchester Hospital 881 cases; mortality, 12 8peroent. 

Korea, a single epidemic W> 

Bendz, Copenhagen 38,036 

Ollivier, three Paris hospitals for five years 898 M 

Fleischmann, five epidemics 1,858 10 <> 

The general mortality of the disease may therefore be assumed to be 
from 12 to 14 per cent; it is, however, much higher than this among 

young children, as shown by the following figun 



906 THE SPECIFIC INFECTIOUS DISEASES. 

New York Infant i^sylum . . . 116 cases under 5 years ; mortality, 20 per cent. 

Ashby, Manchester Hospital . 259 " " 5 " " 23 

Bendz not stated " 5 " " 13 " 

Heubner 136 cases " 7 " " 30 

Fleischmann not stated " 4 " " 43 " 

Under five years of age the average mortality from scarlet fever is, 
therefore, between 20 and 30 per cent. 

The fatal cases may be grouped in three classes : first, those due to 
late nephritis, in which the early symptoms of the disease are of moder- 
ate severity or even mild ; secondly, the septic cases, usually associated 
with severe throat symptoms and dying most frequently in the second 
week from exhaustion, or from some local complication, such as laryngitis, 
pneumonia, pleurisy, meningitis, or nephritis ; thirdly, the malignant 
cases, which are overpowered by the poison of the disease in the first two 
or three days of the attack. 

Prophylaxis. — Even the mildest cases should be isolated for six weeks, 
or until desquamation is completed. If complications exist, such as otitis, 
rhinitis, pharyngitis, empyema, or suppurating glands, the quarantine 
should be continued until these conditions are cured. Patients should not 
be allowed to mingle with other children for at least a month after all 
symptoms have subsided, and should be forbidden to sleep with other 
children for three months. Children in the house who have not been 
exposed to the disease should be immediately sent away ; and those who 
have been exposed, separately quarantined for at least a week. After 
recovery, the patient, before mingling with other children, should have at 
least two disinfectant baths, the entire body being scrubbed with soap and 
water and then washed in a solution of carbolic acid (1 to 50) or bichloride 
(1 to 5,000), and every particle of clothing changed. The hair, if long, 
should be cut short, and the scalp thoroughly washed and disinfected. 

The nurse should be quarantined with the patient, and should not 
mingle with other members of the family until a complete change of 
clothing has been made, and hands and face thoroughly disinfected. The 
nurse and all others in close contact with a severe case should use an anti- 
septic gargle four or five times a day and a nasal spray at least twice a day. 

The room should be in that part of the house most easily quarantined, 
usually on the top floor ; during the attack it should be stripped of up- 
holstery, hangings, and carpet, should be freely ventilated, and kept as 
clean as possible, the floor being frequently sprinkled with a bichloride 
solution (1 to 1,000). The presence in the room of vessels filled with 
antiseptic fluids is of no practical value, and often harmful, in that it cre- 
ates a false sense of security. The same may be said of sheets wet in car- 
bolic or other solutions and hung about the room. Carbolic-acid poisoning 
has been known to result from this practice. After an attack it should 
be remembered that the room is probably a greater source of danger than 



SCARLET FEVER. 907 

the patient. Smooth walls should be wiped with damp cloths wrung out 
of a bichloride solution (1 to 2,000), or should be rubbed down very care- 
fully with bread. The wood- work should be washed in the same solution 
and the floor thoroughly scrubbed with it. After a severe case, the walls 
should be painted or whitewashed, or if papered, the wall-paper should 
invariably be renewed and the wood-work repainted. Simply airing a 
room after an attack is of little or no benefit. An instance is on record of 
a patient contracting the disease in a room in which the windows had 
been open constantly for three months. The carpets, bedding, hangings, 
and upholstery are best disinfected by steam. Where this is impossible, 
after a severe case they should be burned ; after milder cases, articles which 
can be boiled should be treated in this manner, and others exposed to sun- 
light for a long time out of doors, or, after having been moistened, should 
be fumigated with sulphur in the sick-room. The mattress should be 
burned. As ordinarily employed, sulphur fumigation is of very doubtful 
efficacy, and should never be alone depended upon. 

The bedclothes, linen, and clothing removed from the patient during 
an attack, should be put at once into a solution composed of zinc sul- 
phate, four ounces, common salt, two ounces, and water, one gallon, and 
afterward boiled at least two hours in the same solution. Instead of 
handkerchiefs, pieces of old muslin, surgeon's gauze, or absorbent cotton, 
should be used for cleansing the nose and mouth of the patient and 
burned immediately. 

The physician in attendance upon a case should leave his coat and 
overcoat in an anteroom, and put on a long gown or rubber coat, button- 
ing tightly at the neck and sufficiently large to cover all his clothing. 
This should always be worn in the sick-room, and boiled or disinfected 
when the case is finished. The physician's visit should not be unduly 
prolonged, and a stethoscope should be used for examining the chest. 
For a single visit the overcoat may be worn in the room, but the clothing 
should be changed before visits to other children are made After every 
visit the physician's hands and face should be thoroughly washed with 
soap and then with a disinfectant solution. 

A physician in attendance upon scarlatinal patients should not attend 
obstetric cases or other patients with recent wounds. The greal liability 
of such cases to contract scarlatina should never he forgotten. If, in 
emergencies, it becomes necessary to attend such patients, the physician 
should change all his clothing and disinfect his bands, face, hair, and 
beard, with the greatesl thoronghni 

Schools are the hot-beds for tin; spread of BCarlet fever. Tl 
sources of danger are the mild or walking cases in which the disease baa 
not been recognised, and the clothing <>f patients who have had a severe 
form of the disease. As a rale, a child should be kepi from Bchool six 
weeks from the beginning of the attack, and the certificate of a physician 



908 THE SPECIFIC INFECTIOUS DISEASES. 

should be required before re-admission, stating not only that the desqua- 
mation is complete, but also that the child is suffering from no sequelae 
Other children in the household should not be allowed to attend schools 
of any kind during the period of active symptoms ; they should be kept 
at home on the average for a month. This precaution is necessary, first, 
because they might carry the disease from the child at home ; secondly, 
because otherwise they might themselves attend school while suffering 
from the disease in a very mild form or during the period of invasion. 
Where the sick child is completely isolated, the danger from the first 
source is very slight. During severe epidemics it frequently becomes 
necessary to close all schools. 

During desquamation the spread of the disease may be in a measure 
prevented by the free use of inunctions and warm baths. The bath 
water should always be disinfected. All the excreta from the patient 
should be disinfected throughout the disease, best by a carbolic solution 
(1 to 20). If cases of scarlet fever are to be transported, this should 
be done only in a vehicle which can be easily disinfected. Under all cir- 
cumstances as few persons as possible should come in contact with the 
patient. 

In general, it is to be remembered that the danger is first from the 
patient, secondly from the room, and thirdly from the nurse. Special at- 
tention should always be given to the complete and immediate isolation of 
the first case which appears in an institution or community, which should 
apply to mild as well as the severe forms of the disease. 

Treatment. — There is as yet no specific for scarlet fever, so that the 
treatment is one of symptoms and complications. Mild attacks require 
no medicine whatever. Children should be kept in bed for at least a 
week after the fever has subsided, and upon fluid diet for a period of three 
weeks. This is an important matter in the prevention of nephritis (page 
618). During the height of the eruption, the intense itching of the skin 
may be allayed by sponging with a weak carbolic-acid solution, or by in- 
unctions with vaseline, or by the free use of rice powder. Plenty of fresh 
air should always be secured in the sick-room. As soon as the fever and 
rash have disappeared, daily warm baths with soap and water should be 
used, after which the entire body should be anointed with carbolized vase- 
line or a one-per-cent ichthyol ointment, or boric acid and vaseline, five 
per cent strength, with the two-fold purpose of facilitating desquamation 
and disinfecting the scales. In case the skin becomes irritated by this 
treatment, bran baths may be substituted for soap and water. The diet 
requires careful attention in all cases. With the exception mentioned 
above, it should be regulated as in other forms of severe illness (page 191). 

The temperature does not usually require interference when it only oc- 
casionally rises to 104° or 104-5° F. But if there is hyperpyrexia, or a tem- 
perature which ranges from 103° to 105° F. or over, antipyretic measures 



SCARLET FEVER. 909 

are called for. Cold is much safer and more certain than drugs. Some- 
times cold sponging is sufficient, but in the great proportion of cases the 
cold pack or the cold bath (pages 47, 48) is required. The pack is almost 
as efficient as the bath, and usually meets with less opposition on the part 
of the parents. The use of cold in the reduction of temperature is espe- 
cially indicated in septic cases with typhoid symptoms, and in those with 
pronounced cerebral symptoms. Where these are severe the bath should 
always be used, and repeated with sufficient frequency to keep the tem- 
perature below 103° F. 

The nervous symptoms are frequently better controlled by ice to the 
head and by cold sponging than by medication. Antipyretic drugs may 
be relied upon to control restlessness and promote sleep, and in mild cases 
to effect a moderate reduction in temperature when this is accompanied 
by great discomfort. Phenacetine is usually to be preferred. For the 
nervous symptoms occurring in nephritis, as stated elsewhere, opium is to 
be used. 

As soon as the pulse becomes weak or rapid and irregular, with a 
feeble first sound of the heart, stimulants should be given, no matter at 
what stage of the disease. In mild or moderately severe cases they are 
not generally required. In septic, or malignant cases, or in those ac- 
companied by severe angina, adenitis, or cellulitis, alcoholic stimulants 
must be used fearlessly — carried even to the full toleration of the patient 
(page 49). Digitalis is next in value to alcohol, and is especially indi- 
cated where the pulse is weak and soft, with a low tension. The fluid 
extract may be given to a child five years old in minim doses, four times 
a day in the beginning, and later, if necessary, with greater frequency. 
Strychnine is also useful, and may be combined with digitalis or given 
separately, the usual initial dose being gr. ^fa to a child of five years. 

The erythematous sore throat requires no treatment except the use of 
a mild antiseptic gargle. If there is profuse nasal discharge, uasal syring- 
ing (page 5G) with a warm saline or boric-acid solution may be used with 
the hope of preventing infection of the middle ear. The local treatment 
of the membranous angina is the same as that of other cases of pseudo- 
diphtheria. Gangrenous inflammation of the tonsils or palate is seme- 
times benefited by injections of a 10-per-cent solution of carbolic acid in 
glycerin, but most such cases prove fatal, no matter what tie- treatment. 

Milder forms of adenitis require no local treatment. When severe, an 
ice-bag should be applied in the ease of older children. If this Is nol 
well borne,for young children a hoi poultice may 1m- used for a Bhorl time 
for the relief of pain. Prolonged poulticing, however, almost invariably 
does more harm than good, and favours suppuration. If 8 orms, 

early incision should he practised. 

It is doubtful if otitis can he prevented by any form of local treat- 
ment. My experience has been that it rarely occurs in cases with mild 



910 THE SPECIFIC INFECTIOUS DISEASES. 

throat symptoms, but that where these are severe it almost invariably 
follows, whatever the treatment employed. The indications, however, are 
to keep the rhino-pharynx as clean as possible by syringing the mouth 
and nose. The indications for paracentesis of the drum membrane are 
the same as in other severe forms of otitis (page 884). The treatment of 
scarlatinal nephritis has been considered in the chapter devoted to Diseases 
of the Kidney (page 618). Diffuse cellulitis of the neck calls for free in- 
cisions early as the only means of preventing extensive sloughing. 

During convalescence, tonics, particularly iron and digitalis, are called 
for. The urine should be frequently examined for a long time ; antisep- 
tic gargles and a nasal spray or syringe should be used as long as a puru- 
lent discharge from the nose or pharynx continues. 



CHAPTER II. / 

MEASLES. 
Synonyms: Rubeola, Morbilli. 

Measles is an epidemic contagious disease, more widely prevalent 
than any other eruptive fever ; very few persons reach adult life without 
contracting it. One attack usually confers immunity. It is highly con- 
tagious even from the beginning of the invasion, and spreads with great 
rapidity from the patient to all susceptible persons exposed. The poison, 
however, does not cling so long to clothing or apartments as does that of 
scarlet fever. Measles has a period of incubation of from eleven to four- 
teen days ; a gradual invasion of three or four days with symptoms of 
an acute coryza ; a maculo-papular eruption which appears first upon the 
face and spreads slowly over the body, and which lasts from four to six 
days. This is followed by a fine bran-like desquamation, which is com- 
pleted in about a week. The mortality is low, except among infants and 
delicate children, where it may reach 30 or even 40 per cent. In institu- 
tions for infants and young children no disease is more to be dreaded 
than measles, not only on account of its severity, but the frequency 
with which, in such subjects, it is complicated by. broncho-pneumonia. 

Etiology. — The essential cause of measles is as yet unknown. It is 
generally believed to be due to a micro-organism, but, as in the case of 
scarlatina, all attempts to isolate it have thus far been unsuccessful. The 
poison is one which possesses remarkable powers of diffusion, but whose 
viability is much less than that of most of the pathogenic germs which 
are known. Only a short exposure is required to communicate the dis- 
ease, and even close proximity to a patient does not seem necessary. One 
instance has come under my own observation where measles was appar- 



MEASLES. 911 

ently conveyed by an exposure of half an hour across a hospital ward, a 
distance of at least fifteen feet. 

Predisposition. — With the exception of young infants, children of all 
ages are extremely susceptible to measles. The disease broke out in a cot- 
tage of the New York Infant Asylum which was occupied by twenty-three 
children, nearly all of them being under two years old ; only four 
escaped, all these being under five months old. Iu an epidemic reported 
by Smith and Dabney, 110 unprotected children, between the ages of 
eight and eighteen years, were exposed and only two escaped. In the 
Nursery and Child's Hospital, during the epidemic of 1S92, there were 
62 children over two years of age ; five were protected by a previous 
attack and escaped ; of the remaining 57 children, 55 took the disease. 
There were also in the institution 113 children under two years old ; of 
this number 78 per cent took the disease ; but although many were exposed, 
not one child under six months old contracted measles. The age of the 
persons affected depends much upon the length of time since the last 
outbreak of the disease. In an epidemic occurring in the Island of 
Guernsey, where the disease had not prevailed for many years, all ages 
were affected, the youngest being twelve days old, and the oldest, a man 
and wife, each aged eighty years. Somer has reported an instance of an 
eruption of measles appearing in a child twelve hours after birth ; the 
mother was suffering from the disease at the time. Gautier has col- 
lected six additional cases, where measles either existed at the time of 
birth or developed within a few hours after it. 

Except, then, in early infancy, the probabilities are very strong that 
every child exposed to measles will contract the disease. Occasionally, 
however, one is seen who seems insusceptible to the poison, no matter how 
close the exposure. 

Epidemics of measles are more frequent and more severe during the 
spring months. They are least frequent and mildest during the autumn 

months. 

Incubation.— In 144 cases,* where the period of incubation could be 

definitely traced, it was as follows : 

Incubation of less than nine daya 

" " nine or ten days 

« " eleven to fourteen days WS 

«• " fifteen to seventeen days 19 

" " eighteen to twenty-two daya ■» 

Thus in 66 per cent of the cases the incubation was between eleven and 
fourteen davs, and in only one case was il less than a week. Theconstanoj 

* About twenty-five of these are taken from my own r rdo; the remaind 

mainly isolated eases, scattered through medical literature. The incubation is reck- 
oned from the time of exposure to the beginning of the catarrh. 



912 THE SPECIFIC INFECTIOUS DISEASES. 

of the incubation period is strikingly shown in some epidemics. Thus 
in the one reported by Smith and Dabney in an institution in Virginia, 
exactly eleven days after the rash appeared in the first case, the disease 
developed in twenty children — no cases having occurred in the in- 
terval. 

Duration of the infective period. — This is much shorter than in 
scarlet fever, and the average duration may be placed at four weeks. 
Haig-Brown discharged fifty-eight cases on or before the twenty-ninth 
day of the disease, and in no instance was measles spread by these chil- 
dren. Eansom, however, records one instance in which it was communi- 
cated thirty-one days after the appearance of the rash. 

Measles is highly contagious from the beginning of the catarrhal 
symptoms. A case occurred in the Babies' Hospital under my own ob- 
servation, in which a child conveyed the disease four days before the rash 
appeared. Ransom reports another precisely similar. An instance has 
been related to me by Dr. S. W. Lambert, where, of thirteen little girls 
who were at a children's party, only one escaped measles, the source of in- 
fection being a child who showed no rash until the following day ; the 
child who escaped had previously had measles. The period of greatest 
contagion is still a matter of dispute, the general belief being that it is 
coincident with the highest temperature, the full eruption, and the most 
severe catarrhal symptoms. 

With the fading of the eruption and the subsidence of the catarrh, the 
communicability of measles diminishes rapidly. It is relatively feeble 
during desquamation, and soon after this period it usually ceases alto- 
gether. It is generally proportionate to the severity of the catarrhal 
symptoms, and where these are protracted it is probable that the disease 
may be communicated for a much longer period than that mentioned. 

Mode of infection. — Measles is usually spread by direct contagion, very 
infrequently through the medium of clothing, furniture, or a third person. 
Townsend (Boston) records an instance in which one family moved into 
a tenement house on the same day on which it was vacated by another 
family in which two children had suffered from measles, one of them 
fourteen and the other eighteen days previously. The apartments were 
not fumigated nor disinfected, and, although there were two susceptible 
children in the incoming family, they did not contract the disease. 
Measles rarely if ever clings to apartments for weeks or months, as does 
scarlet fever. Many instances are on record in which the disease has been 
carried by a third party ; but, after all, this rarely happens, unless the con- 
tact both with the sick and the well child is very close and the interval 
short. It is very seldom that measles is carried by a physician who takes 
even the ordinary precautions. In a case reported by Girom, the clothing 
of a patient is stated to have conveyed the disease nineteen days after an 
attack, but this must be regarded as very exceptional. 



MEASLES. 913 

Lesions. — The only constant lesions of measles are those of the skin 
and the mucous membranes, chiefly of the respiratory tract. According 
to Neumann, the process in the skin is of an inflammatory character, but 
is more superficial than in scarlet fever. There is congestion, accom- 
panied by an exudation of round cells about the small blood-vessels, and 
also about the sweat and sebaceous glands, and the papillae. To this 
exudation and the oedema, the swelling of the skin is due. It occurs 
everywhere, but is especially noticeable upon the face. 

The changes in the mucous membranes are quite as much a part of 
the disease as are those of the skin. There is a catarrhal inflammation 
affecting the conjunctivae, nose, pharynx, larynx, trachea, and large 
bronchi, which varies in intensity with the severity of the attack. In the 
most severe forms in infants and in young children, this inflammation 
extends with great uniformity to the small bronchi, and usually to the 
air vesicles, causing broncho-pneumonia. In severe cases, the lesion in 
the pharynx and larynx also, instead of being catarrhal, may be mem- 
branous ; the larynx being much more frequently involved, and the ears 
much less so, than in scarlet fever. The lesions of the lungs and of other 
organs will be more fully considered under Complications. 

The bacteria which are associated with the lesions of the respiratory 
tract are, in the milder cases, usually the staphylococcus, and in the more 
severe ones the streptococcus, although this is sometimes reversed. They 
may be found separately or together, and either form may be associated 
with the pneumococcus (see Bacteriology of Broncho-Pneumonia, page 
482). The poison of measles produces conditions in the mucous mem- 
branes of the respiratory tract which are especially favourable for the 
development of these bacteria, which at such times are always present in 
the mouth in large numbers. Many of the other complications besides 
pneumonia are due to infection \vith- these germs. Associated with the 
lesions of the mucous membranes, are found changes in the lymphatic 
glands with which they are connected ; they may be of a hyperplastic or 
of a suppurative character. 

Symptoms. — Invasion.— As a rule, the invasion of measles is gradual, 
both the fever and catarrhal symptoms increasing steadily up to the appear- 
ance of the eruption. The characteristic symptoms of the invasion are 
those of a severe coryza, — suffusion of the eyes, increased lachrymation, 
photophobia, sneezing, and a discharge from the nose. The hoarse, hard 
cough indicates that the catarrhal process has involved the laryns and 
trachea, as well as the visible mucous membranes. Frequently the patient 
complains of some soreness of the throat, and on inspection there ifi seen 
moderate congestion of the tonsils, fauces, and pharynx. <>n the hard 
palate are frequently seen on the second or third day Bmall red spots, from 
the size of a pin's head to that of a pea. Thia is sometimes Bpoken of as 
the eruption upon the mucous membrane. The constitutional -num. 

67 



914 THE SPECIFIC INFECTIOUS DISEASES. 

are indefinite, and may be met with in almost any disease. There are 
dulness, headache, pains in the back, and the usual symptoms of malaise ; 
there is rarely vomiting or diarrhoea. Drowsiness is a frequent symptom, 
and is regarded by the laity as characteristic. 

The exceptional cases in which the invasion is abrupt are puzzling. 
There may be a sudden accession of fever with vomiting, and even con- 
vulsions, as in a case lately under my observation. Not infrequently, when 
the disease prevails epidemically, the invasion is sudden, with high fever 
and pulmonary symptoms which are so severe as to mask everything else 
until the rash makes its appearance, the case up to that time being often 
regarded as one of primary pneumonia or of influenza. The duration of 
the stage of invasion— i. e., from the beginning of the catarrh until the 
eruption — in 270 cases of which I have notes, was as follows: 

6 davs 20 cases. 

7 "' 6 " 



1 day or less 35 cases. 

2 days 47 " 

3 " 64 " 

4 " 64 " 

5 " 29 " 



8 " 2 " 

9 " 2 " 

10 " 1 case. 



From this table it will be seen that the length of the period of invasion 
varies considerably, — more, I think, in infants and very young children 
(most of these were under three years old) than in those who are older. 
In the greater number of cases it lasts from two to four days. 

Eruption. — The rash usually appears on the third, fourth, or fifth day 
of the disease — in the largest number upon the fourth day. As a rule, it 
is first seen behind the ears, on the neck, or at the roots of the hair over 
the forehead. It appears as small, dark-red spots, which are at first few, 
scattered, and not elevated, resembling flea-bites. In twenty-four hours 
the macules are much more numerous, and many of them have become 
papules. They frequently group themselves in crescentic forms. They 
are usually separated by areas of normal skin, but where the rash is intense 
they are frequently coalescent. From the time of its first appearance to 
the full development of the rash on the face, is usually about thirty-six 
hours, but may be from one to three days. With a full eruption there is 
considerable swelling of the face, especially about the eyes, and the features 
are sometimes scarcely recognisable. On the second day of the rash it 
begins to appear upon the neck beneath the chin, the upper part of the 
chest and back ; on the third day the trunk is covered, and scattered spots 
are seen upon the extremities. The rash appears last upon the lower ex- 
tremities, and by the time it is fully out upon them it has usually begun 
to fade from the face. In mild cases it remains discrete, but in severe 
ones it is frequently confluent upon the face and upon the extensor surface 
of the extremities. As a rule, it covers the entire body, even the palms 
and soles. 

The eruption fades slowly in the order of its appearance, and there is 



MEASLES. 915 

left behind, in typical cases, a slight brownish staining of the skin, which 
often remains for nearly a week. The duration of the rash is from one to 
six days, the average being four days. 

There are many cases in which the rash does not follow the typical 
course described : (1) Instead of spreading gradually, the entire body 
may be covered in a- few hours. (2) The rash may be hsemorrhagic. 
This condition was present in about five per cent of my cases. The 
whole eruption may be haemorrhagic, or it may be so only upon certain 
parts — usually the abdomen or extremities. Under such circumstances 
small petechial spots take the place of the macules. This is the " black 
measles" of the older writers. It is in most cases a bad, but by no 
means a fatal symptom. I have seen it in several cases that were not 
especially severe. (3) The rash may be very faint, and of short duration, 
being scarcely elevated at all. (4) It may consist of very minute papules, 
closely resembling the rash of scarlet fever. It is to be remembered, how- 
ever, that the irregular eruptions of scarlet fever much more frequently 
resemble measles than vice versa. (5) It may be very scanty, and late in 
its appearance ; particularly in cases of great severity and hyperpyrexia — 
the so-called malignant cases. (6) Temporary recession of the eruption 
may occur at any time during the height of the disease, and is usually 
due to heart failure. A recurrence of the eruption after it has run its 
usual course is something which I have never seen ; although such cases 
have been reported, I believe them to be very .exceptional. 

During the first two days of the eruption, the local and constitutional 
symptoms increase in severity, both usually reaching their maximum at 
the time of the full development of the rash upon the face. The skin 
is swollen, and the seat of intense itching and burning. The eyes are 
very red and sensitive to light, and there is swelling of the conjunctiva 
with an abundant production of mucus or muco-pus, causing the lids to 
adhere. There is pain on swallowing, also swelling of the gJands at the 
angle of the jaw or in the post-cervical region. The cough is frequent 
and very annoying. There is complete anorexia, and often diarrhoea. 
The tongue is coated, and may show at its margin enlarged papilla', 
resembling the "strawberry" appearance of scarh-l fever. A.8 the rash 
fades the temperature declines rapidly, often reaching the normal in two 
or three days. The catarrhal symptoms now subside, and Boon the pan. ait 
is convalescent. Within a day or two after the fever has ceased, the rash 
disappears. 

Desquamation.— This begins almosl ae booh ag the rash has subsided, 
and is first noticed on the face and neck, where the eruption firsl ap- 
peared. The nature of the desquamation is invariably fine, branny scales, 
never in large patches, as in scarlet fever. It is often quite indistinol and 
may be overlooked. Its usual duration is from five to ten days. It may, 
however, be prolonged for two weeks. The am. ami of desquamation varies 



916 



THE SPECIFIC INFECTIOUS DISEASES. 



considerably in the different cases. It is most marked in those in which 
there has been an intense eruption. There is frequently noticed at this 
time an odour about the patient which is quite characteristic of measles. 
During this stage the cough often persists and the eyes remain weak and 
very sensitive to light, but in other respects the patient usually feels per- 
fectly well. 

1. The mild cases. — The mildest cases are distinguished by low tem- 
perature, which at the height of the eruption usually reaches 102° F., but 
rarely lasts more than four days. The eruption is often scanty, and is 
never confluent. The swelling, itching, and other cutaneous symptoms 
are wanting, as is also the intense red colour of the skin. The rash is 
frequently obscure, and, without the other symptoms, hardly sufficient for 
diagnosis. The catarrhal symptoms are more uniform than the rash, but 
these are very mild as compared with the usual form. The duration of 
the rash is shorter, desquamation is scarcely perceptible, and there are no 
complications. 

2. The cases of moderate severity. — The course of measles is much 
more regular in children over three years old than in infancy. In the 
former, the symptoms of invasion come on gradually, and the temperature 
rises steadily until the appearance of the eruption, which is in most cases 



DAY 


1 


2 


3 


i 


5 


c 


7 


s 


H 

I 
Z 

u 
<r 

I 


ioc c 
ior, c 

104° 
103° 
102° 
101° 
100° 

99 C 

98° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 








X 
















A 














r 


A 














/ 




, 








A 


/ 


J 












/ 


V 






s 








/ 










\s* 


X 


















\S 



UAY 


1 


2 


3 


4 . 


> 6 


7 


8 


9 


LU 

r 
z 
in 

a 

I 
< 


10C° 
100° 
101° 
103° 
102° 
101° 
100° 
99° 


M E 


M E 


M E 


MEM 


E M E 


a e 


M E 


M L 






x 


« 


X 














A 














h 


[l\ 


A 














S 


!\ 










A 




v 


L 










P 


J 




V^v 


V\ 






S 




V 








\A 
















V 


U 



Fig. 158. 



Fig. 159. 



Fig. 158. — Temperature curve in uncomplicated measles, showing the gradual rise and critical 
fall ; patient ten years old ; x = first eruption ; * = full eruption on the face. 

Fig. 159. — Typical curve in uncomplicated measles, with gradual rise and gradual fall ; patient 
three years old. 



on the third or fourth day of the disease. Figs. 158 and 159 represent 
the typical temperature curve in average uncomplicated cases. Such a 
curve was seen in 44 per cent of 173 cases in which careful observations 
were made. Sometimes the decline in the fever is very rapid, almost. a 
crisis, as in Fig. 15S, but more often it falls gradually, as in Fig. 159. In 
such cases the duration of the fever is from five to nine days, the average 
being about a week. The other symptoms follow very closely the course 
of the fever. The maximum temperature is nearly always coincident with 



MEASLES. 



917 



the full rash upon the face, at this time usually being in uncomplicated 
cases from 103° to 104° F. in older children, and 10-4° to 105° in infants 
and young children. 

A not very uncommon temperature curve is that of Fig. 160, where 
the onset of the disease is 
marked by a sudden rise to 
102° or even 104° F., with a 
fall nearly or quite to nor- 
mal on the second day, after 
which the fever rises grad- 
ually, as in the first group. 
This curve was seen in 5 per 
cent of my cases. 

3. The severe cases. — In 
Fig. 161 is shown a type of 
the disease which is more 
frequent in infants than in 
older children, the impor- 
tant features being the late 

eruption and the continuance of the high fever for several days after the 
rash has begun to fade. Such a prolonged course and so high a temper- 
ature are almost invariably due to some complication, usually broncho- 
pneumonia. Where the pneumonia goes on to the production of areas 



DAY 


1 


2 


3 


1 


5 


c 


r 


8 


9 | 10 


11 


12 


K 

I 
2 
ill 
K 

X 
< 


106° 
105° 
101° 
103° 
102 C 
101° 

100° 
99° 
98 c 


M E 


M E 


M E 


M E 


M E 


M E 


H E 


M E 


M E 


M E 


V E 


M E 














x 






















X 


* 


x 




















\ 














\ 






/ 


/ 


v\ 












\ 






/ 


\ 






\ 












y 




/ 


V 






\ 












\, 


V 












vA 


v 


r 






V 


V 














\ 


/ 





Fig. 160. — A not infrequent temperature curve in mea- 
sles, showing abrupt invasion, but subsequent course 
typical; uncomplicated case: patient nine months 
old. 




Fig. 161.— Measles with prolonged invasion: continuance of hijrh temperature after lull eruption 
due to severe bronchitis and diarrhoea; child two years old. 

of consolidation, the fever usually continues for three and sometimes for 
four weeks, even though terminating in recovery. 

Figs. 162 and 163 illustrate two types oi the disease which are often 
seen when measles is complicated by pneumonia. In cases like thai Bhown 
in Fig. 162 the onset is abrupt with high temperature, prostration, and 
pulmonary symptoms not unlike those of primary pneumonia. A tem- 
perature curve resembling thi< was Been in 28 of 173 cases. The rash is 
often late in appearance; it is faint and altogether irregular; it may 



918 



THE SPECIFIC INFECTIOUS DISEASES. 



recede after the first day and reappear after an interval of one or two 
days. The catarrhal symptoms are not marked, but the whole force 
of the disease seems to be expended upon the lungs. The diagnosis of 
these cases presents great difficulties, and very often it would not be 
made but for the fact that there are other cases of measles in the family 
or the institution. This form is usually seen in infants, and it is very 
fatal. 

In other cases marked by a sudden severe onset, the system seems to be 
overpowered by the poison of the disease itself. There are profound de- 



DAY 


1 


2 


3 


i 


5 


c 


7 


8 


9 


10 


H 
HI 

I 
z 

<r 

I 

2 


106° 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 


M E 






X 














f 


104° 
103° 
102° 
101° 
100° 
99° 
98° 






A 












1 




A 


/ 


\ 


lT 


J 


V 


v 


v 


1 




/ 


V 






V 


V 


V 


V 






/ 








V 


















y 




















i 



































DAY 


1 


2 


3 4 


5 


H 

I 
z 
tu 
tc 

I 
< 
u. 


108° 
107° 
100° 
105° 
104° 
103° 
102° 
101° 
100° 

99° 
98° 


M E 


M E 


MEM 


E M E 






I 


X 






/ 


h 






1 


i 






/ 


m 






/ ' 






fi 


/ 






/ 






/" 


V 






/ 

















Fig. 162. 



Fig. 163. 



Fig. 162. — Fatal attack of measles, complicated by broncho-pneumonia; very severe symptoms 

from the onset ; patient eighteen months old ; death on tenth day. 
Fig. 163.— Fatal attack of measles, complicated by broncho-pneumonia ; early invasion mild, but 

rapid development of severe symptoms on fourth day ; rash on last day ; patient eight 

months old. 

pression, and hyperpyrexia, and the patient may die from toxaemia with 
cerebral symptoms before the appearance of the rash or just as it is begin- 
ning to show itself. Sometimes the pulmonary symptoms are entirely 
wanting ; at others the rash, if it appears, is hemorrhagic. 

In still another group of cases the onset is not violent, and for the first 
two days the attack may appear to be of only average severity ; but there 
may then develop, often quite suddenly, pulmonary symptoms of such 
intensity as to cause death within twenty-four hours. The eruption, if 
seen at all, is faint and not characteristic (Fig. 163). 

A secondary rise in the temperature after it has once fallen to normal 
was seen in 8 of 173 cases, being due to the development of otitis, ileo- 
colitis, or late pneumonia. 

Complications and Sequelae. — The most frequent and most important 
complication of measles is broncho-pneumonia, and next to this are ileo- 
colitis, otitis, and membranous laryngitis. Most of the others are in- 
frequent; all complications are relatively rare in children over four 
years old. 



MEASLES. 919 

Lungs. — The greatest danger in measles arises from pulmonary com- 
plications, and the frequency is greatest in children under two years of 
age. In two epidemics in the Nursery and Child's Hospital, embracing 
about 300 cases, nearly all in children under three years old, broncho- 
pneumonia occurred in about 40 per cent of the cases. Of those who 
had pneumonia, 70 per cent died. Fortunately, such a record as this is 
never seen outside of asylums or hospitals for young children. Of 2,477 
cases, embracing several epidemics of measles among children of all ages, 
pneumonia occurred in 10 per cent. My own experience in the post- 
mortem room fully bears out the statement of Henoch, that a certain 
amount of pneumonia is found in almost every fatal case. Pneumonia is 
more frequent and its mortality is higher in spring and winter epidemics 
than in those occurring at other seasons. It may develop at any time from 
the beginning of invasion until convalescence, but it most frequently 
begins about the time of full eruption. 

Lobar pneumonia, although rare, occasionally occurs as a complication 
in children over three years old. In some epidemics many of the cases 
of pneumonia are complicated by severe pleurisy, which adds much to 
the danger of the disease. This form is frequently followed by empyema. 
Pneumonia is always to be suspected when the temperature continues high 
after the full appearance of the rash. 

Bronchitis of the large tubes, always accompanied by tracheitis, is 
seen in every case of measles, possibly excepting a few of the very mild- 
est. This is so constant a feature as hardly to be ranked as a complica- 
tion. In nearly all of the severe cases the bronchitis extends to the me- 
dium-sized and smaller tubes. 

Larynx. — A mild catarrhal laryngitis accompanies almost even case 
of measles. Severe catarrhal laryngitis is present in about ten per cent of 
the cases; it may give symptoms which closely resemble those of mem- 
branous laryngitis, and the two are no doubt often confused. (For the 
points of differential diagnosis see page 443.) 

Membranous laryngitis is more often seen as a complication of measles 
than of scarlet fever. It was present in 35 of 2,837 eases taken from 
miscellaneous sources ; but in epidemics in institutions it is much more 
common than this. As a cause of death in older children it ranks next 
to pneumonia. When it develops at the height of the disease, as it usu- 
ally does, it is due in nearly all cases to the streptococcus; but when it 
develops at a later period, it is usually due to tie- diphtheria bacillus. The 
streptococcus inflammation is in most cases associated with Bimilar changes 
in the pharynx or tonsils, bat not always. True diphtheria, occurring 
as a complication of measles, not infrequently begins in the larynx, 'I'll'' 
streptococcus inflammation may he as Berious in this connection as is true 
diphtheria, from the probability, which amounts aim 08 1 to a certainty, of 
the development of broncho-pneumonia. No complication is more to be 



920 THE SPECIFIC INFECTIOUS DISEASES. 

dreaded than this. The diagnosis between the true and pseudo-diphtheria 
may sometimes be made by the time of development, but only with cer- 
tainty by cultures. I once saw in measles, where no false membrane was 
present in the rest of the larynx, a necrotic inflammation with almost 
entire destruction of the vocal cords — a condition which may be compared 
to that seen in the tonsils or epiglottis in scarlatina. 

Throat. — A catarrhal angina is part of the disease, and is as charac- 
teristic of measles as is the eruption upon the skin. There is acute con- 
gestion and swelling of the tonsils, uvula, palate, and pharynx. In a 
certain proportion of cases, very much less frequently than in scarlatina, 
the development of membranous patches is seen upon the tonsils and ad- 
jacent mucous membranes. These occur in two or three per cent of the 
cases. They are to be regarded in the same light as similar conditions 
complicating scarlet fever (page 899), with these differences, that in 
measles there is much greater likelihood of the extension of the disease 
to the larynx, while extension to the nose and ears is much less probable. 
True diphtheria, however, may complicate measles, and cases of mem- 
branous inflammation of the tonsils or pharynx developing late in measles 
are usually due to the Loeffler bacillus. 

Although in most cases the inflammations of the pharynx and tonsils 
which accompany measles are not serious when they are due to the strep- 
tococcus, they are sometimes quite as severe as any that accompany scarlet 
fever. They may cause death from general sepsis apart from any affec- 
tion of the larynx. 

Digestive system. — Gastric disorders are not more common than in 
other febrile diseases; but diarrhoea is very frequent, and in summer it 
may be even more serious than the pulmonary complications. All forms 
of diarrhoea are seen, from that which results from simple indigestion to 
the severe types of ileo-colitis. This complication is most often seen in 
children under two years old. The most severe intestinal symptoms are 
not usually seen at the height of the primary fever ; but, beginning at this 
time, they often increase in severity, and are most marked in the second 
and third weeks of the disease. 

Catarrhal stomatitis is present in almost every case of measles; less 
frequently the herpetic form is seen. Ulcerative stomatitis is not uncom- 
mon, particularly in institutions. One of the worst complications of 
measles, but fortunately a rare one, is gangrenous stomatitis, or noma. 
This usually occurs in inmates of institutions, or in children with bad 
surroundings who were previously in wretched condition. It is nearly 
always fatal. 

Gangrenous inflammations of other parts of the body are sometimes 
seen after measles, especially of the vulva or the prepuce. 

Nervous system. — I have seen convulsions at the onset of measles in 
but a single case. During the progress of the disease they are not so rare, 



MEASLES. 921 

and may occur in connection with otitis, meningitis, or severe broncho- 
pneumonia — chiefly in infants. 

Meningitis is rare, but either the simple or the tuberculous form may 
occur, more often, however, as a sequel than as a complication. Insanity, 
usually of a temporary character, occasionally follows measles. In the 
epidemic of 108 cases reported by Smith and Dabney, insanity was noted 
three times, all the cases terminating in recovery. Epilepsy and chorea 
ar.e rare sequela?. 

Ears. — Otitis is not so frequent as in scarlet fever, and in many epi- 
demics it rarely occurs ; in others it is often seen. In one hospital epi- 
demic it was noted in 14 per cent of the cases. This epidemic occurred 
in early spring and affected very small children, both of which circum- 
stances are favourable for the development of otitis. Usually both ems 
are affected, and the inflammation terminates in suppuration ; but the 
otitis of measles is, as a rule, much less serious than that of scarlet fever, 
and much less frequently leads to permanent impairment of hearing. 

Eyes. — Simple catarrhal conjunctivitis accompanies nearly every case 
of measles. In the severe form there is a muco-purulent catarrh, which 
may attain any degree of severity. In neglected cases, and among chil- 
dren who are poorly nourished, especially in asylums, the disease is apt to 
extend to the cornea. In a very large number of cases chronic conjunc- 
tivitis persists after measles, particularly in the class of children just 
mentioned. 

Lymph nodes.— Swelling of the lymphatic glands of the neck is fre- 
quent, but not generally severe, and rarely terminates in suppuration. In 
a considerable proportion of cases chronic enlargement persists for months, 
and sometimes the glands may become tuberculous. Similar changes and 
similar consequences may occur in the glands of the tracheo-bronchial 

group. 

Kidneys.— The infrequency of renal complications in measles is m 
striking contrast to scarlet fever. Transient febrile albuminuria is not 
uncommon, but a serious degree of nephritis, either clinically or at au- 
topsy, I have never seen, and literature furnishes bul few cases. Demme 
and Browning have eacl^ reported cases of nephritis following measles, in 
which death occurred from uraemia. 

// e ^._Both endocarditis and pericarditis have occurred in the course 
of measles, but they belong to the ran- complications. The same ma) be 
said of changes in the muscular walls of the heart. 

Skin.— As complications, erysipelas, furunoulosis, impetigo, and pem- 
phigus have been noted; but all an- rare. 

Hemorrhages.— Associated with tie- h»morrhagic type of the eruption, 
severe and even fatal haemorrhages may occur from the mucous mem- 
branes, and the latter are sometimes seen without the bamorrhagic 
eruption. 



922 THE SPECIFIC INFECTIOUS DISEASES. 

Other infectious diseases. — Measles may be complicated by almost 
any of the other infectious diseases — scarlet fever, varicella, diphtheria, 
etc. It is rare that the two processes are exactly simultaneous, but one 
usually develops as the other is subsiding. Epidemics of measles and 
whooping-cough more frequently occur together, or follow each other, 
than do any of the others. The relation of measles to tuberculosis seems 
to be particularly close. In some of the cases, tuberculosis follows directly 
in the wake of measles, an irregular temperature continuing from three 
to eight weeks, when death occurs from general tuberculosis with the 
principal lesions in the lungs. Acute miliary tuberculosis may follow 
even more closely. As a late manifestation, the most common one is 
tuberculosis of the bones, occurring as hip-joint disease, caries of the 
spine, etc. The relation of measles to tuberculosis seems to be that it 
furnishes conditions, especially in the lungs, which are favourable for the 
development of tuberculosis in patients who have been previously infected, 
but in whom the disease has been latent in some part of the body, espe- 
cially in the lymph nodes. In other cases measles seems greatly to increase 
the susceptibility of the patient, so that tuberculosis is subsequently con- 
tracted after the slightest exposure. The frequent association of these 
diseases should never be forgotten, and on this account an attack of mea- 
sles in a child with tuberculous antecedents should always be looked 
upon with apprehension. 

Diagnosis. — The most important symptoms for diagnosis are the 
coryza, at first slight, but steadily increasing in severity, the gradual rise 
in temperature, and the maculo-papular eruption, appearing first upon the 
neck and face, and slowly extending over the body. Before the rash a 
diagnosis is impossible. When it is faint and of doubtful character, 
a hot mustard bath will often bring it out so distinctly as to make a diag- 
nosis easy. In cases where the rash is irregular in its character or time of 
appearance, great importance is to be attached to the catarrhal symptoms, 
especially the condition of the eyes. The appearance of the throat and 
the fine red spots upon the hard palate are also important. The cases 
which present the greatest difficulties are the very severe ones and those 
in infants. Mild attacks are more characteristic than are the mild forms 
of scarlet fever. 

From skin diseases, measles is distinguished by its temperature, which 
is rarely less than 102-5° F. at the height of the eruption ; from other 
general diseases by the rash itself. 

Prognosis. — This depends upon the age and previous condition of the 
patient, the character of the epidemic, and the season of the year at which 
it occurs. Except in children under three years of age, the deaths from 
measles are few ; but in institutions containing little children, no epidemic 
disease is so fatal. The following statistics illustrate the general mortality 
of the disease as it has been observed : 



MEASLES. 923 

Krauss and Hirschberg, Dresden Hospital, 49 years 1,461 cases; mortality, 4-2 per cent. 

Sagoiski, St. Petersburg Hospital, 11 years 7,050 " " 9 2 " 

Embden, one epidemic 461 " " 6*7 " 

Demme, Berne Hospital, in one epidemic 224 " " 5*8 

Alteberg, one epidemic 725 " " 1 2 

Fleischmann 736 " " 22*0 

Bendz, Copenhagen 30,581 " " 3 -0 " 

The average mortality of the disease is thus from four to six per cent ; 
but in epidemics observed in institutions containing only young child ren 
it is much higher. Henoch records an epidemic of 294 cases among chil- 
dren, nearly one half of whom were under two years of age, with a mor- 
tality of 30 per cent. In the epidemic of 1892, in the Nursery and Child's 
Hospital, New York, there were 143 cases, with a mortality of 35 per cent. 
The figures of the epidemic of 1895 were almost identical. All these 
children were inmates of the institution at the time they were taken ill, 
and, although many were delicate, few were suffering from other dis- 
eases when they were attacked with measles. The following table 
gives the exact figures of the epidemic of 1892 : 

From six to twelve months 42 cases ; mortality, 33 per cent. 

" one to two years 51 " 50 " 

" two to three years 27 " 30 

" three to four years 20 " 14 " 

" four to five years 3 " 

The average mortality among children under two years is probably not 
far from 20 per cent, but it is much higher in institutions. The death- 
rate diminishes rapidly after the second year. 

In any single case the important symptoms for prognosis are the tem- 
perature and the character of the eruption. An initial temperature above 
103° F., or one which remains high until the eruption appears, is a bad 
symptom. So also is one which rises after a full eruption, or which docs 
not fall as the rash fades. The following table shows the highesl tem- 
perature and mortality in 101 hospital cases: 

Highest temperature not over 102° 6 cases; mortality, per oent 

102^ to 103 -5° 14 " - ~ 

104° " 104 5 49 " " 16 

105° " 105-5° 86 M " 40 " 

106° or over 27 " M 80 

A favourable eruption is one of a bright colour, covering the body, re- 
maining discrete, and spreading gradually. It is unfavourable for the 
eruption to appear late, to be very Paint, scanty, or haemorrhagic, or to 
recede suddenly, as this is usually due to a weak heart. 

Of 51 fatal cases, the cause of death was broncho-pneumonia in 46, 
ileo-colitis in 4, and membranous laryngitis in 2. More than ball 
deaths occurred during the second week, the earliesl bi ing upon the fifth 
day of the disease. 



924 THE SPECIFIC INFECTIOUS DISEASES. 

The ultimate result of an attack of measles may not be evident for 
some time. Cases in which the temperature persists for two or three 
weeks without assignable cause after the disease is apparently over, should 
be watched with the greatest solicitude. The explanation of this is most 
frequently to be found in the lungs, although the physical signs are often 
obscure. The condition may be either subacute pneumonia or pulmonary 
tuberculosis. Even though the attack of measles may not have been in 
itself severe, seeds are often sown the full fruits of which are not seen 
until long afterward. Chronic glandular enlargements which may or 
may not be tuberculous, chronic bronchitis, chronic laryngitis, subacute 
or chronic nasal catarrh, hypertrophy of the tonsils, and adenoid growths 
of the pharynx, — all are frequent sequelae. 

Prophylaxis. — Measles is often regarded by the laity as so mild a 
disease that its prevention is thought of little importance, and no effort 
is made to limit its extension. The great probability that every person 
at some, time in his life will have the disease, is no justification of unneces- 
sary exposure. Although in older children measles is usually mild, this 
is not so in infants, who should be carefully protected from exposure. 
Special care should also be taken to avoid the exposure of delicate children 
or those with a strong tendency to pulmonary disease or to tuberculosis. 
In institutions it is of the utmost importance to secure prompt and com- 
plete isolation of the first case which appears. 

The disease being usually spread by the patient and rarely from apart- 
ments, it follows that while early isolation is more important, there is not 
required the same thorough cleansing and disinfection which should follow 
every case of scarlet fever. In an institution, the ward or cottage from 
which a case has been removed should be quarantined for at least sixteen 
days after the appearance of the last case, and absolute security can not 
be said to exist until the end of three weeks. The same rule should be 
applied in private families where children who have been exposed 
should be quarantined apart from the patient, but not sent away. Under 
ordinary circumstances the quarantine of a case of measles should last 
four weeks from the beginning of invasion. It should be continued louger 
if there is pneumonia, otitis, or a nasal discharge. 

Thorough cleansing and disinfection of the sick-room should be done 
before it is again occupied by children, and it should remain vacant at 
least two weeks. Children should be kept from all schools while the 
disease is in their homes, chiefly because they- are otherwise liable to spread 
the disease while suffering from the early symptoms of invasion. 

Treatment. — Measles is a self-limited disease, and there are no known 
measures by which it can be aborted, its course shortened, or its severity 
lessened. The indications are therefore to treat serious symptoms as they 
arise, and, as far as possible, to prevent complications, which are the prin- 
cipal cause of death. 



MEASLES. 995 

The sick-room should be darkened, as the eyes are very sensitive to 
light. Every child with measles should be put to bed and kept there with 
light covering during the entire febrile period. There can be no possible 
advantage in causing a child to swelter by thick blankets, under the delu- 
sion that the disease may be modified thereby. The food should be light, 
fluid, and given at regular intervals. If the conjunctivitis is severe, iced 
cloths should be applied to the eyes, which should be kept clean by the fre- 
quent use of a saturated solution of boric acid, the lids being prevented 
from adhering by the application of vaseline or simple ointment. The 
intense itching and burning of the skin may be relieved by inunctions of 
plain or carbolized vaseline. The cough, when distressing, may be allayed 
by small doses of opium, either in the form of the brown mixture or by 
equal parts of paregoric and glycerin, of which from five to thirty drops 
may be given, according to the age of the child, every two hours. The 
restlessness, headache, and the general discomfort which accompany the 
height of the fever may be relieved by an occasional dose of phenacetine or 
antipyrine. As soon as the rash has subsided, a daily warm bath should be 
given, followed by inunctions to facilitate desquamation and prevent the 
dissemination of the fine scales. 

The important indications to be met in the severe cases are very high 
temperature, cardiac depression, and nervous symptoms — dulness, stupor, 
sometimes coma, or convulsions. In some of the cases there are in addi- 
tion dyspnoea and cyanosis, showing severe acute pulmonary congestion. 
For the nervous symptoms and high temperature, nothing is so reliable 
as the cold baths or packs (pages 47 and 48) and the nearly continuous 
use of ice to the head. I do not think there is any evidence that the use of 
cold increases the liability to pneumonia ; but cold extremities, feeble pulse, 
and cyanosis, when associated with high temperature, call for the hoi mus- 
tard bath, although ice should still be applied to the head. The indications 
for stimulants and the methods of using them are the same as in broncho- 
pneumonia (page 510), which is usually present in cases requiring them. 
To diminish the chances of pneumonia, it is necessary that every pa- 
tient should be kept in bed during the attack, and care exercised to avoid 
exposure; that the chest should be protected with flannel and rubbed 
daily with oil. But still more importanl is ii in hospitals and institutions 
where most of the cases of pneumonia occur, to allow the patients plenty 
of air space, never crowd in g them together in small wards. If possible, 
cases complicated by pneumonia should be separated from simple c 
From the fact that the pneumocoocus and the streptococcus are found in 
the mouth so constantly and in such numbers in cases complicated by 
pneumonia, Mety and Boulloque have suggested systematic disinfection 
of the mouth several times a day, will, the purpose of preventing this 
complication. There is reason in this suggestion, although its efficacy 
has not yet been put to a practical test. 



926 THE SPECIFIC INFECTIOUS DISEASES. 

The bronchitis and broncho-pneumonia of measles should be managed 
as in cases where they occur as primary diseases, as the coexistence of 
measles furnishes no new indications. The same is true of the diarrhoea, 
conjunctivitis, and otitis. Membranous laryngitis, pharyngitis, or ton- 
sillitis should be treated like other cases of pseudo-diphtheria. Should 
cultures show the presence of the diphtheria bacillus, the case should be 
treated like one of ordinary diphtheria in the same situation. 

During convalescence the eyes should be used very carefully for at 
least several weeks. Should the cough and slight fever persist, with or 
without physical signs in the chest, the patient should, if possible, be sent 
away to a warm, dry, elevated district, as the development of tuberculosis 
is always to be feared. Cod-liver oil should be given continuously 
throughout the succeeding cool season, and iron, wine, and other tonics 
according to indications. The cough itself should be treated as when it 
follows an ordinary bronchitis (page 470), creosote being more generally 
useful than any other drug. 



CHAPTER III. 

RUBELLA. 

Synonyms : German measles ; rotheln. 

Rubella is a contagious eruptive fever which is rarely seen except 
when prevailing epidemically. It is characterized by a short invasion, 
with mild, indefinite symptoms, usually lasting but a few hours, and by an 
eruption which is generally well marked but of variable appearance. The 
constitutional symptoms are very mild, and the disease rarely proves fatal, 
not often being even serious. For a long time rubella was confounded 
with measles and scarlet fever, as the eruption sometimes resembles one 
and sometimes the other disease. Its identity is now fully established, 
and, as Striimpell well says, its existence is doubted only by those who 
have never seen it. The following peculiarities have been stated by 
Griffith (Philadelphia), who has written more fully on rubella than any 
other American writer, and to whom I am indebted for many facts in this 
article : 

(1) Rubella is a contagious, eruptive fever, and not a simple affection 
of the skin ; (2) it prevails independently either of measles or of scarlet 
fever ; (3) its incubation, eruption, invasion, and symptoms, differ materi- 
ally from those of both these diseases ; (4) it attacks indiscriminately and 
with equal severity those who have had measles and scarlet fever and 
those who have not, nor does it protect in any degree against either of 
them ; (5) it never produces anything but rubella in those exposed to its 
contagion ; (6) it occurs but once in the individual. 



RUBELLA. 927 

Etiology. — Kubella is beyond question contagious, but is decidedly 
less so than either measles or scarlet fever; so that some observers have 
doubted its contagion altogether. It can be communicated at any time 
during its course, but is especially contagious during the early stage. 
Epidemics usually prevail in the winter or spring. As in the other 
eruptive fevers, a striking immunity is seen in infauts under six months 
old ; but, with this exception, all ages are liable to the disease. 

The incubation of rubella varies considerably ; the usual period is 
from eight to sixteen days, although the limits are from rive to twenty-two 
days. 

Symptoms. — Invasion. — This is rarely more than half a day, and in 
many cases no prodromata whatever are noticed, the rash being the first 
thing to attract attention. In a few cases there are mild catarrhal symp- 
toms, with general malaise and slight fever. At other times there may be 
vomiting, convulsions, delirium, epistaxis, rigors, headache, or dizziness ; 
but all are to be regarded as very exceptional. 

Eruption. — Frequently a child wakes in the morning covered with the 
rash, no symptoms having been previously noticed. It generally appears 
first upon the face, and spreads rapidly to the whole body, the lower ex- 
tremities being last covered. Less than a day is usually required for its 
full development. Exceptionally the eruption comes first upon the chest 
and back, and sometimes nearly the whole body is covered almost at once. 
The rash has occasionally been observed in the roof of the mouth before 
it was visible on the face. In a considerable number of cases the en tin' 
body is not covered ; but the rash is more constantly seen upon the face 
than upon any other part. 

Its character is subject to considerable variation. The eruption is 
most frequently composed of very small maoulo-papules ; they are of ;i 
pale-red colour, and vary in size from a pin's head to a pea. The spots 
are usually discrete, but may cover the greater part of the body where ii 
is seen. On the face it is frequently confluent, and often appears here 
as large, irreaular blotches of a red colour. From this description the 
rash will be seen to resemble that of measles more than that of any other 
disease. Very often, however, there is a tolerably uniform red blush which 
bears a close resemblance to the rash of scarlet fever; hut even in such 
cases there will nearly always he found upon some pari <>f the body, usu- 
ally the wrists, fingers, or forehead, some typical maculo-papules. Between 
these two extremes all variations are Been. The colour of the eruption is 
sometimes dark red, and rarely it has been noted to he hemorrhagic. The 
degree of elevation above the surface is also variable ; Bometimee this 
marked as to give to the skin a^'shotty" feel, while in others the elevation 
is scarcely perceptible. The duration of the eruption is usually three days. 
Occasionally it lasts only two days, and it may last hut one; it le rare for 
it to remain as long as four days. It fades in the order of its appearance, 



928 THE SPECIFIC INFECTIOUS DISEASES. 

and more rapidly than the eruption of measles. A slight brown pigmen- 
tation of the skin sometimes remains for a few days after the rash. 

The highest temperature is coincident with the full eruption ; this does 
not usually exceed 102°, and often it is only 100° F. As a rule, the tem- 
perature continues but two days, falling as the eruption fades. Very 
often the fall to normal is abrupt. Rarely severe cases are seen in which 
the fever lasts for four or five days, being 101° or 102° F. during the inva- 
sion, and rising to 104° or 105° F. during the full eruption. The other 
symptoms are in most cases even less marked than the fever. Occasionally 
catarrhal symptoms resembling a mild attack of measles are present, or a 
sore throat suggesting mild scarlet fever; but more frequently all these 
are absent. The eruption is usually out of all proportion to the other 
signs of disease. 

Swelling of the post-cervical glands is one of the most constant fea- 
tures of rubella. In most epidemics it is seen in nearly all cases ; but as a 
symptom for differential diagnosis it is not of great importance, as it is 
not uncommon in measles. The glandular swelling is most marked at the 
height of the disease ; it is never very great, and subsides slowly without 
suppuration. Both vomiting and diarrhoea are rare in rubella. Swelling 
and itching of the skin are occasionally present, but to a much less extent 
than in scarlet fever or measles. 

Desquamation. — This is always slight, and occurs in very fine scales 
lasting from one to five days. In many cases it can be discovered only by 
the most careful examination, and occasionally it is entirely wanting. 
Writers who have observed some fairly typical epidemics have stated that 
desquamation did not occur. 

Cbmplications and Sequelae. — A characteristic feature of rubella is the 
absence both of complications and sequelae. In the great majority of 
cases none are seen. Isolated instances have been reported in which have 
occurred, severe bronchitis or pneumonia, severe catarrhal pharyngitis, al- 
buminuria, diarrhoea, phlyctenular conjunctivitis, multiple abscesses, otitis, 
erysipelas, and urticaria ; but all are to be regarded as very exceptional. 

Prognosis. — There are few diseases so free from danger as rubella. 
A fatal termination is extremely rare, and is usually due to pulmonary 
complications. Squire makes the significant statement that if the mor- 
tality reaches three per cent the disease is not rubella, but measles. 

Diagnosis. — The principal interest attaching to rubella is in its diag- 
nosis. This is a matter of extreme difficulty, and often it is an impossi- 
bility. The most characteristic thing about the disease is a well-marked 
eruption with very few other symptoms. Cases so closely resemble mild 
scarlet fever or mild measles that the differentiation by symptoms is im- 
possible ; it must be made from the surroundings and the fact that the dis- 
ease is prevailing epidemically. Scarlet fever with a low temperature and 
abundant rash should always be regarded with suspicion, as should mea- 



VARICELLA. 929 

sles with a doubtful or absent catarrh. These difficulties iu diagnosis can 
be appreciated only by one who has seen epidemics of measles and scarlet 
fever in institutions, and has watched the mild course of undoubted cases 
of these diseases which have there occurred. 

It is never safe to make the diagnosis of rubella unless the disease is 
prevailing epidemically. Sporadic cases in which the diagnosis is made 
are, I believe, almost invariably instances of mild measles or scarlet fever. 
The first cases of rubella in an epidemic thus become difficult of recog- 
nition and are often overlooked. The continued absence in succeeding 
cases of the characteristic symptoms and complications of measles or scar- 
let fever should suggest to the physician that he is probably dealing with 
rubella. 

Treatment. — None whatever is required for the disease excepting iso- 
lation, and even this is not imperative. The individual symptoms and 
complications are to be met with as they arise. 



CHAPTER IV. 

VARICELLA. 

Synonym : Chicken-pox. 

Varicella is an acute, contagious disease, characterized by a cuta- 
neous eruption of papules and vesicles and by mild constitutional Bymp- 
toms, serious complications and sequelae being very rare. Although long 
confounded with varioloid, its existence as a distinct disease has been gen- 
erally admitted for many years. 

Etiology.— It is well established that the eontagium of the disease ia 
contained in the vesicles, as it may be communicated by inoculation with 
their contents. The specific poison, however, has doI yel been isolated 
Varicella is contracted by exposure to another case or through the medium 
of a third person. It affects children of all ages, one attack being ae a 
rule protective. It is very contagious, resembling measles m thia resj 
The duration of incubation is quite uniformly from fourteen to Bixteen 

days. . . ,. 

Symptoms -Slight fever and general indisposition may be noticed for 

twenty-four hours before the appearance of the eruption, but m n 

cases the eruption is the first symptom. It usually appear* first upon 

the face, scalp, or shoulders, as B mall, red, widely-scattered papules, 

spreads slowly over the trunk and extremities. The papules in mosl 

come in crops, new ones continuing to appear for three or four days, even 

upon the same part of the body. The earlier ones have generally begun to 

dry up by the time the later ones appear, bo thai all stages ol the eru] 

may be present at one time in the same region, this being one ol its mosl 

68 



930 THE SPECIFIC INFECTIOUS DISEASES. 

diagnostic features. The papules are at first very small, but gradually in- 
crease in size, and are surrounded by an areola from one fourth to half an 
inch in width. Many of them go no further than this stage, but the ma- 
jority become vesicular. The vesicles are usually flat, and vary a good deal 
in size — the largest, being about one fourth of an inch in diameter. The 
process of drying up generally begins at the center, which causes a slight 
depression, giving the vesicle a somewhat umbilicated appearance. The 
areola is most distinct at the time of the fully-formed vesicle, and fades 
as the latter dries. Crusts now form, which fall off in from five to twenty 
days, depending upon the depth to which the skin has been involved. In 
the majority of cases no mark is left, but after the most severe attacks, 
where the true skin has been involved, scars remain, and occasionally 
there is quite deep pitting. Such marks are few in number, and are most 
likely to occur upon the face. 

Sometimes, especially upon hands and feet, the vesicle appears without 
having been preceded by a papule ; often there is no areola, and the vesi- 
cle resembles a drop of water upon healthy skin. In most cases pustules 
are not seen, but they may develop in consequence of irritation or infec- 
tion, the result of scratching, or in children who are poorly nourished. 
Under these circumstances deeper ulceration may occur, lasting for weeks. 
In rare cases there may be a necrotic inflammation about the site of the 
pock, a condition to which is sometimes given the name varicella gangre- 
nosa. It is not peculiar to varicella, and is described elsewhere under the 
head of Gangrenous Dermatitis (page 872). 

The pocks are usually most abundant over the back and shoulders, and 
their number is in proportion to the severity of the disease. In mild 
cases only twenty or thirty may be found upon the entire body, but in 
severe cases the skin may in certain regions be nearly covered. The erup- 
tion is never confluent. The pocks are almost invariably seen on the 
hairy scalp, and frequently three or four may be found on the mucous 
membrane of the mouth or pharynx, — a point of some diagnostic value. 
In the latter situation the appearance is first a tiny vesicle, and later a 
superficial ulcer resembling that of herpetic stomatitis. 

The temperature is highest when the eruption is most rapidly appear- 
ing, this usually being the second or third day. In an average case it 
reaches only 101° or 102° F., and lasts but two days ; in severe cases it 
may rise to 104° or 105° F., and last for four or five days. It falls gradu- 
ally to normal as the rash fades. The other symptoms are mild and 
not characteristic. There is no coryza, cough, vomiting, or diarrhoea, 
but instead only the general indisposition which accompanies any febrile 
disorder. 

Complications. — The most serious complication is erysipelas, which 
develops about the pocks, particularly when they are deep and attended 
with some ulceration. I have known of three fatal cases from this cause. 



VACCINIA.— VACCINATION. 931 

Adenitis, either simple or suppurative, and abscesses in the cellular tissue, 
are occasionally seen. Xephritis is very infrequent, but a number of cases 
are recorded. It may occur at the height of the disease, but more often 
at a later period, like the nephritis of scarlet fever. Varicella is quite 
frequently complicated by other infectious diseases. In the New York 
Infant Asylum epidemics of varicella and scarlet fever at one time oc- 
curred together, and in at least a dozen children both diseases were seen 
at the same time. 

Diagnosis. — The diagnosis of varicella is usually easy, provided the 
following points are kept in mind : First, that the eruption comes out 
slowly and in crops, so that papules, vesicles, and crusts may be seen upon 
the skin in close proximity ; secondly, that the umbilication is due only 
to the mode of drying up of the vesicle, which begins at the center ; 
thirdly, the appearance of the pocks upon the mucous membranes, and 
the history of exposure. It is distinguished from urticaria and other 
forms of skin disease by the presence of fever. 

Treatment. — Although it is usually a trivial disease, isolation of cases 
of varicella should be enforced in schools and in institutions containing 
many infants. In the home, unless the other children are delicate or in 
poor condition, quarantine is unnecessary. The disease may probably Id- 
conveyed as long as the crusts are present, hence isolation should be 
maintained until they have fallen off. In most cases constitutional symp- 
toms of the disease are so mild as to require no treatment. 

Locally, the itching, when annoying, may be allayed by sponging with 
a weak solution of carbolic acid or the use of carbolized vaseline. When 
the crusts have formed, this ointment or vaseline containing two per cent 
ichthyol should be applied. Care is necessary to keep the skin dean, and, 
in the case of infants, to prevent scratching. In severe cases the urine 
should invariably be examined. 



CHAPTER V. 
VACCINIA— VACCINATION. 

Vaccinia (cowpox) is a febrile disease induced in man by inocula- 
tion with the virus obtained either directly from the cow (bovine rirua) 
or from a person who has been inoculated (humanized virus). The 
ease is not contagious in the ordinary Bense of the term, but is communi- 
cated by inoculation either accidental or intentional. 

The nature of the protection againsl Bmallpox which vaccination 
affords is even now but imperfectly understood. The fact, however, re- 
mains one of the best attested in medical history. It is the imperative 
duty of the physician to see to it that every young infant is vaccinated, 



932 THE SPECIFIC INFECTIOUS DISEASES. 

and no foolish sentiment or prejudice on the part of the parents should 
be allowed to stand in the way. 

Re-vaccination. — Eegarding the duration of the protective power of a 
single vaccination, positive statements are impossible. Nearly all writers 
are agreed that vaccination should be done in infancy, again at puberty, 
and a third time at about the age of twenty or twenty-five. Many also 
insist upon re-vaccination at about the seventh year. It is a safe rule 
when smallpox is prevalent to vaccinate every person who has not been 
successfully vaccinated within five years. 

Choice of Virus. — Modern experience is quite unanimous in the substi- 
tution of bovine for humanized virus, the advantages being that the lymph 
is much more likely to be obtained pure, uncontaminated by the germs of 
erysipelas or suppuration, and that the risk of transmitting syphilis is 
thereby avoided. There is now no difficulty in obtaining the ivory or 
quill points used for the preservation of bovine virus. There are many 
vaccine farms which can be depended upon for the purity and freshness 
of the virus which they supply.* 

Time for Vaccinating. — In selecting a time for vaccination, the child's 
age and general health must be taken into consideration. It is pretty well 
established that the constitutional disturbance is much less in infancy 
than in later childhood, and less in very young infants (under one month) 
than in those of five or six months. Wolff states that of forty-two infants 
successfully vaccinated during the first week of life, not one showed any 
constitutional disturbance ; after the fifth month, however, febrile symp- 
toms were invariably present, and occasionally severe. A good rule for 
general practice is to vaccinate every healthy infant as soon as it begins 
to gain regularly in weight, this being in most cases during the first two 
months of life. In delicate infants or in those whose nutrition is a 
matter of great difficulty, those who are syphilitic, those suffering from 
eczema or any other form of active skin disease, vaccination should be 
deferred until the child is in good condition, unless it is likely to be ex- 
posed to smallpox. As a rule, vaccination should be avoided during den- 
tition. 

Methods of Vaccinating. — In my experience it is better to vaccinate in 
one place rather than to make two or three inoculations. Either the leg 
or the arm may be chosen ; in young infants it is usually easier to protect 
the vaccine sore upon the leg than upon the arm. The point selected for 
inoculation should be the outer aspect of the left calf, about the junction 
of the middle with the upper third of the leg, or the insertion of the left 
deltoid. The skin should be washed with soap and water, dried, and then 
washed with alcohol. With an ordinary large-sized cambric needle, which 

* My own experience with that of the New England Vaccine Company of Massa- 
chusetts has been extremely satisfactory. 



VACCINIA.— VACCINATION. 933 

should be a new one, three or four scratches should be made a quarter of 
an inch long, and these crossed by as many more, just deeply enough to 
draw blood. The moistened vaccine point is now thoroughly rubbed for 
a full minute over the wound. After this has dried thoroughly the part 
may be covered with isinglass plaster moistened in boiled water, although 
if thorough drying has taken place the plaster is not necessary. The 
needle should not be used for a second child. The vaccinated limb should 
not be washed for twenty-four hours. 

The Normal Course of Vaccinia. — The course of a proper vaccination- 
pock is quite uniform, and one which does not follow this course should 
not be considered protective. The original wound heals like any other 
scratch, nothing of importance being seen until the fourth or fifth day, 
when a slight areola is visible about the site of inoculation, which enlarges 
until it is an inch or two in diameter. Then there rises a vesicle, some- 
times two, which afterward coalesce. The vesicle is from one fourth to 
one half an inch in diameter, and has a depressed centre (Fig. 164). By 
the ninth or tenth day the fully-formed vesicle is seen. The areola is 
now two or three inches wide, and there is more or less swelling. The 
lymph nodes in the axilla, or in the groin if the leg has been inoculated, 
are slightly swollen, tender, and sometimes painful. The vaccine pock 
changes but slightly for a day or two, after which, usually upon the 
eleventh day, the areola fades, the vesicle ruptures and discharges, or dries 
to a crust, this process occupying about two days. The crust remains for 
from one to three weeks, when it falls off leaving a smooth bluish 
which afterward fades to a white, and becomes somewhat honeycombed. 

In some cases the symptoms are more severe. There may be swelling 
of the whole limb and marked pain. The original vesicle may be t* 
three times as large as usual, and secondary vesicles may form in the 
neighbourhood (Fig. 105). The inflammation may extend deeply into 
the subcutaneous tissue, and it maybe followed by suppuration or even 
sloughing. There is then left an ugly nicer, sometimes an inch wide and 
one fourth of an inch deep, to be filled slowly 03 granulation, [n such 
cases the whole course of the disease may be from five to eighl weeks. 

If in a young infant the first inoculation is unsuccessful, a1 least three 
trials should be made with good virus, and in the event of further failure, 
after a year vaccination should be repeated. A failure to inoculate does 
not mean insusceptibility to smallpox, as is often popularly believed, but 
most frequently arises from the fact that the virus is inert. 1 have known 
one case in which the seventh, and another in which the thirteenth, inocu- 
lation was successful after previous failures; occasionally there are 
children who can not be inoculated al all. 

Constitutional symptoms, as previously stated, are often sbeent in the 
case of very young infants; but in others there is quite constantly present 
a fever which runs a fairly regular course. It usually begins on the fourth 




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VACCINIA.— VACCINATION. 935 

or fifth day, is remittent in type, and rises gradually, reaching its high- 
est point with the full development of the vesicle. At this time it varies 
from 101° to 104° P., falling gradually to normal. The duration of the 
fever in cases running the usual course is four or five days. Accompany- 
ing it there may be anorexia, restlessness, loss of sleep, slight indigestion, 
and other symptoms of a general indisposition. 

Variations in the Course of Vaccinia.— Occasionally the period of in- 
cubation is prolonged, and no evidence that the inoculation has been 
successful is seen for from ten to fourteen days, or even longer, and yet 
the subsequent course may be normal. In some cases multiple pocks are 
present, which may be produced by auto-inoculation, usually by scratch- 
ing. They may be only in the neighbourhood of the original one, 01 
upon any other part of the body. In cases of eczema of the face, inocu- 
lation has not infrequently been carried thither. A generalized eruption 
of pocks is sometimes seen, although this is very rare. In secondary 
vaccination both the local and general symptoms may be quite as into 
as in the primary cases, and in many instances they are even more severe. 

Complications and Sequelae.— Post-vaccine eruptions occur in meat 
variety, and from three quite distinct causes. Even with pure virus there 
may be urticaria, erythema, or a general roseola which often resembles 
the eruption of measles, and occasionally purpura has been seen. As 1 lie- 
result of mixed infection at the time of the original inoculation, there 
may be produced impetigo contagiosa, syphilis, or even tuberculosis. 
From subsequent infection of the vaccination wound, there may be I'lirun- 
culosis, cellulitis, or erysipelas. The complications are in the main the 
result of the causes just enumerated. In addition to the diseases men- 
tioned, there may be pyemia, gangrenous dermatitis, suppurative adenitis, 
and in rare cases pneumonia or nephritis. Sequelae are very rare; but 
where latent constitutional tendencies have existed they may be aroused 
to activity, as in the case of tuberculosis. A child who has once had ecze- 
ma is liable to a recurrence at such a time; and in very delicate children 
a condition of malnutrition is frequently intensified if the vaccinia baa 
been particularly severe. 

The mortality of vaccination is stated by Voigt, from careful statis- 
tics drawn from German sources, to have been 35 in 2,275,000 cases, in- 
cluding both primary ami secondary vaccinations. Of the deaths, 1'.' 
were due to erysipelas, 8 to gangrene, 'I to cellulitis, 3 to kfc blood pofc 
ing," and 3 to other causes. It will be observed thai these were all, or 
nearly all, from preventable causes. 

Treatment. — The purpose of this is simply cleanliness and protection, 
to prevent the irritation of clothing, and also to prevent the child from 
scratching, for by these means the vesicle usually becomes infected. No 
treatment is required until the vesicle has forme,!. The limb Bbould then 
be protected by clean linen, or, better, by a vaccine Bhield, of which one 



936 THE SPECIFIC INFECTIOUS DISEASES. 

made of a wire network and fastened to the limb by a tape, is probably the 
best form. As soon as the vesicle ruptures and begins to discharge serum, 
it should be frequently dusted with boric acid. If there is suppuration, 
the pock should be treated antiseptically, like any other granulating 
wound. If a vaccinated limb is kept perfectly clean, and the pock dry 
by the free use of the powder mentioned, very little trouble need be ap- 
prehended. If the local symptoms are at all severe, the limb should be 
kept at rest. For this reason, a child old enough to walk should not be 
vaccinated upon the leg. 

The complications are to be treated as when these conditions arise un- 
der other circumstances. 



CHAPTER VI. 

PERTUSSIS. 

Synonym : Whooping-cough. 

Peetussis is a contagious disease which prevails epidemically and in 
most large cities endemically. Although it may affect persons of any 
age, it is generally seen in young children, and as a rule it occurs but once 
in the same individual. While in later childhood pertussis may be ranked 
as one of the milder infectious diseases, in infancy it is one of the most 
fatal. Its principal complications are broncho-pneumonia and convul- 
sions. Pertussis is characterized by catarrhal and nervous symptoms. 
The catarrh affects the mucous membranes of the respiratory tract, and is 
probably due to a specific form of infection. It is accompanied by a hyper- 
assthetic condition of these mucous membranes. The most prominent 
nervous manifestation is a peculiar spasmodic cough which occurs in par- 
oxysms, and from which the disease takes its name. The cough is no 
doubt of reflex origin, from an irritation which by different writers has 
been located in various parts of the respiratory tract. In addition to these 
conditions, there is present in pertussis a very marked irritability of the 
nervous system generally, which in infancy frequently shows itself by 
convulsions. 

Etiology. — Pertussis is probably due to a micro-organism, but its nature 
is as yet unknown. Proximity to a patient is all that is required to com- 
municate the disease, and as in the case of measles even close proximity is 
not necessary. There seems to be no doubt, from clinical experience, that 
the disease may be contracted in the open air. 

Predisposition. — Fully one half the cases of pertussis occur during the 
first two years of life. This statement, which is in accord with general 
experience, is borne out by the following statistics of Szabo (Buda-Pesth), 



PERTUSSIS. 937 

showing the ages at which the disease was met with in 4,591 cases, com- 
prising the records of one clinic for thirty-four years : 

Under one year 1,028 cases. Three to four years 904 i 

One to two years 1,008 " j Four to seven years 803 - 

Two to three years 659 M ' Over seven years 189 

Pertussis thus shows a stronger tendency to affect very young infants 
than does any other contagious disease. It not infrequently occurs during 
the first six months of life, a number of cases are on record in which it 
has occurred during the first month, and one has recently come to mv 
notice where a child twelve days old was attacked, whose mother was 
suffering from the disease at the time the child was born. Statistics taken 
from a large number of epidemics show that the disease is nearly twia 
frequent in the winter and spring as in the summer and autumn. Epidem- 
ics of pertussis often occur at the same time with or follow those of men - 

The susceptibility to pertussis is very great, and is equalled only by 
that to measles. Biedert reports that of 401 children exposed during an 
epidemic in a certain village, 36G, or ninety-one per cent, took the disease. 

Infective period. — Pertussis may be communicated from the very bo- 
ginning of the catarrhal stage; exactly how long a given case may be 
contagious it is impossible to say positively. It is pretty certain that it is 
so during the entire spasmodic stage, and probably longer. In most cases 
quarantine is required for three months from the beginning of the attack, 
and in many cases for a much longer time. The usual source of the con- 
tagion is the patient, rarely the room or the clothing. While it is possible 
that pertussis may be carried by a third party, this is very unlikely un 
a person has been in very close contact with a patient, and goes at once 
without change of clothing to another child. 

Incubation.— The very gradual onset of pertussis renders it impossible 
in the majority of cases to fix the exact date, and hence to establish the 
definite duration of the period of incubation. In cases where it could best 
be determined it has usually been found to be from seven to fourteen 
days, or about the Baine as measles. If, after an exposure, sixteen days 
without the development of a cough, the probabilities are ver) thai 

the disease has not been contracted. 

Lesions.— The only constant Lesions of pertussis consisl in a catarrhal 
inflammation of varying intensity, which affects the mucous membrane <>f 
the larynx, trachea, and bronchi, and Bometimes that of the nose and 
pharynx. If the child dies during a paroxysm, either with or withoul con- 
vulsions, the brain is found intensely congested and mav be the Seal <»f 
punctate haemorrhages, or even larger extravasations. The lunj 
show emphysema if the attack Has been severe or protracted. The other 
pulmonary lesions are due to complications, the mosl frequent «.f which i< 
broncho-pneumonia. Catarrhal enteritis and colitis are uot infrequent 

69 



938 THE SPECIFIC INFECTIOUS DISEASES. 

Symptoms. — The symptoms of pertussis are usually divided into three 
stages — the catarrhal, the spasmodic, and the stage of decline. 

The catarrhal stage continues on the average for about ten days, al- 
though cases show considerable variation on this point. Some children 
whoop almost from the very beginning of the disease, while others may 
cough for several weeks before a typical whoop is noticed. The symp- 
toms in the beginning are indistinguishable from those of an ordinary 
attack of subacute tracheo-bronchitis, and unless there has been an expos- 
ure to pertussis no suspicion is excited. After five or six days, however, 
the cough, instead of abating as in an ordinary cold, gradually increases 
in severity and occurs in paroxysms. At first these are mild, and there 
are only two or three a day, but they gradually increase in frequency and 
severity until the typical whoop is heard which marks the beginning of 
the spasmodic stage. During the first stage there may be symptoms of a 
mild grade of catarrhal inflammation of the nose, pharynx, and larynx, 
and often there is a slight elevation of temperature. 

The spasmodic stage. — In a typical paroxysm of average severity the 
child, who can usually foretell it, will often run for support to the lap of 
the mother or the nurse, or seize a chair with both hands. There now 
occurs a series of explosive coughs, from ten to twenty in number, coming 
in such rapid succession that the child can not get its breath between 
them ; the face becomes of a deep red or purple colour, sometimes almost 
black ; the veins of the face and scalp stand out prominently ; the eyes 
are suffused, and seem almost to start from their sockets ; there follows a 
long-drawn inspiration through the narrowed glottis, producing the crow- 
ing sound known as the whoop ; and then another succession of rapid 
coughs follows and another whoop. In a single severe paroxysm, which 
lasts two or three minutes, the child may whoop half a dozen times ; with 
the final paroxysm a mass of tenacious mucus is usually brought up. 
The most common attendant symptoms of the paroxysm are vomiting 
and epistaxis. In a young child vomiting is almost certain to follow, if 
food has been recently taken. Epistaxis sometimes occurs with nearly 
every severe paroxysm, but in most cases the bleeding is slight. After 
such an attack as that described, a child is at times so exhausted as to be 
hardly able to stand; there is profuse perspiration; his mind is confused, 
and he may be completely dazed. In infants the attack may result in a 
degree of asphyxia so deep as to necessitate artificial respiration. 

The number of severe paroxysms or " kinks " in twenty- four hours 
varies, according to the severity of the case, between half a dozen and 
forty or fifty. There are always many more of a milder form. Paroxysms 
are often excited by eating or drinking anything which is cold, by a 
draught of air, or by imitation; they are usually more frequent during 
the night than the day, and in a close room than in the open air. 

In less severe cases no paroxysms of the grade above described may 



PERTUSSIS. 939 

occur, and no typical whoop may be heard throughout the attack ; but 
the paroxysmal nature of the cough which continues until the plug of 
mucus is raised, the watery eyes, and the vomiting which follows a par- 
oxysm, stamp the disease as pertussis. In young infants the whoop is 
frequently not marked. The child sometimes coughs until it is asphyxi- 
ated, and yet no whoop occurs. The paroxysms are also modified by inter- 
current disease, especially by attacks of pneumonia or severe bronchitis. 
At such times they usually become less frequent and less typical, and may 
be absent for several days, returning as the complication subsides. 

The seat of irritation which produces the cough has been located by 
different observers in different mucous membranes : some have thought it 
to be in the nose, others in the trachea, the bronchi, or the larynx. It is 
very probable that it may not always be in the same mucous membrane; 
and that the infectious catarrh, which is really the most important ele- 
ment in the disease, may vary in its intensity and location in different 
cases. The weight of evidence seems to be that in the great majority of 
cases the source of irritation is in the larynx or trachea. From laryn- 
goscopic examinations made during the disease, Von Herff found the 
mucous membrane of the larynx to be swollen and congested, and occa- 
sionally the seat of small haemorrhages or superficial ulcers. He states 
that the frequency and severity of the paroxysms corresponded with the 
degree of laryngitis, and he found that a paroxysm could always be ex- 
cited by irritating the mucous membrane between the arytenoid cartity 
During a paroxysm he observed that there was a collection of mucus on 
the posterior laryngeal wall, the removal of which had the effect of short- 
ening the paroxysm. 

Eossbach made laryngoscopy examinations, with negative results so 
far as the larynx was concerned, but he states that a ping of mucus could 
always be seen in the lower trachea for one or two minutes before the 
paroxysm occurred. There is little doubt that this collection of nun 
the exciting cause of the paroxysm, as it is a familiar clinical fact that 
the paroxysm always continues until this is dislodged. 

The average duration of the spasmodic stage is about one month. If 
increases in intensitv for the first two weeks, remains stationary for about 
a week, and then gradually diminishes in severity. The course and dura- 
tion are, however, subject to wide variations. In mil. I caa 
may last only a week ; in Bevere cases, especially in the winter Beason, ri 
may continue for three months, at tine- greatly subsiding, but Ligl 
up again with all its previous severity with every fresh attack of cold. 
After it has entirely ceased the whoop may return with an attack of bron- 
chitis, and continue for a month or more. This is do( to be 
as a true relapse of pertussis. The habit of the paroxysmal cough 
established, it tends to recur with every slighl bronchitis, of ten for months 
afterward. 



940 THE SPECIFIC INFECTIOUS DISEASES. 

The stage of decline. — Gradually the severity of the paroxysm abates, 
the whoop ceases, and the cough resembles more and more that of ordi- 
nary bronchitis. This stage usually continues about three weeks, but 
may be prolonged indefinitely in the winter months. 

Complications. — Hemorrhages. — The haemorrhages of pertussis are 
mechanical, and depend upon the intense venous congestion which ac- 
companies the paroxysm. Epistaxis is the most frequent variety, and 
occurs in a considerable proportion of the severe cases, in a few with al- 
most every severe paroxysm, but it is rarely severe enough to require local 
treatment. Haemorrhages from the mouth may have their origin either 
in the pharynx or the bronchi, the blood being brought up by the cough ; 
such haemorrhages are usually small. Conjunctival haemorrhages are less 
frequent, and are usually slight, although I have seen the entire conjunc- 
tiva of one eye covered. In a case under my observation there was bleed- 
ing from both ears with every severe paroxysm, for more than a week. 
This child had previously suffered from scarlatinal otitis, with perfora- 
tion of the drum membrane. Small extravasations into the cellular 
tissue beneath the eyes are occasionally seen, giving an appearance some- 
what like an ordinary " black eye." Intracranial haemorrhages are not 
frequent, but many examples have been recorded, and they may be severe 
enough to produce death. They are usually meningeal, very rarely cere- 
bral ; according to their extent and location they may produce hemiplegia, 
monoplegia, aphasia, facial paralysis, or disturbances of the special senses 
of sight, hearing, sensation; in addition, there may be convulsions or 
rigidity, but rarely complete coma. The extravasations are usually small, 
and the symptoms which they produce disappear at the end of a few 
weeks. Fatal cases with autopsies have been reported by Cazin, Marshall, 
and others. In almost every instance these haemorrhages have occurred 
as a direct result of severe paroxysms of the cough. Purpura haemor- 
rhagica as a sequel of pertussis was twice seen at the New York Infant 
Asylum. 

Respiratory system. — The most serious complications of pertussis are 
connected with the lungs. By far the largest proportion of deaths is due 
to pulmonary complications, usually broncho-pneumonia. This is more 
frequent in winter and spring than in the summer months, and is espe- 
cially to be dreaded during infancy. In later childhood lobar pneumonia 
is occasionally seen. Pneumonia rarely begins before the second week 
of the disease, and most frequently develops at the height or toward the 
close of the spasmodic stage. The physical signs present no peculiarities ; 
the cough changes somewhat in character during the pneumonia, and 
the whoop may not be heard. The prognosis of the pneumonia is bad, 
because of the debilitated condition of the children at the time of its 
occurrence. A great danger is from the supervention of convulsions, this 
being a frequent mode of termination. As there is always considerable 



PERTUSSIS. 941 

emphysema the rapidity of breathing is frequently out of proportion to the 
temperature, which often is only moderately elevated. If the child escapes 
the dangers of the acute stage, death may still occur from exhaustion, 
owing to the protracted course which the disease frequently runs.* 

Bronchitis of the large tubes is present in almost all the severe cae 
and is not of itself serious. Bronchitis of the small tubes has the same 
dangers and the same complications as broncho-pneumonia. 

Vesicular emphysema has been present, I think, in every case which I 
have seen upon the post-mortem table; a certain amount of it, no doubt. 
occurs in every severe case. It is produced by the forcible cough of the 
paroxysm. In very severe cases interstitial emphysema is also found. 
Northrup has reported a remarkable instance of this complication. Rup- 
ture of the air-blebs which form on the surface of the lung, may lead to 
emphysema of the cellular tissue of the mediastinum, and the air may 
find its way along the great vessels into the neck, and finally into the sub- 
cutaneous cellular tissue of the entire body. Oases of general subcutane- 
ous emphysema have been reported by Croker and Hodge, both of which 
ended fatally, one in three and one in eight days from the beginning of 
the emphysema. In the great majority of the cases vesicular emphysema 
is not permanent. 

Digestive system.— Timing the summer, infants with pertussis are 
almost certain to suffer from diarrhoea; it may be only an occasional 
symptom, or the attack may be severe and prolonged, resulting in the de- 
velopment of ileo-colitis. The intestinal complications may be aim. 
serious in summer as are those of the respiratory tract in winter. \ mint- 
ing is even more frequent than diarrhoea, and, while it may be distressing 
at any age, it is especially so in infancy. So frequently does the taking 
of food excite vomiting, that the nutrition of these patients often becomes 
a matter of the greatest difficulty, and in fact the most serious problem 
in the management of a case. Malnutrition and even marasmus may 
follow, or the general resistance of the child may become bo reduced by 
lack of food that it falls a ready prey to pneumonia. 

Nervous system.— There may be convulsions, coma, paralysis, aphasia, 
disturbances of sight or hearing, and in rare cases even of the mental con- 
dition. The most serious of these complications are convulsions. They 
are much more frequent in infancy than later, and are particularly 
those who are rachitic, where they are often fatal. Oonvulsioi 
course more common in severe attacks, but they may occur Buddenly where 
there has previously been no cause for anxiety. They are especially to be 
dreaded if pneumonia is present. The attack of convulsions may be the 
culmination of the extreme degree of nervous irritability which m 
panies the paroxysm, it may be due to asphyxia, or to an intracranial 



For further particulars regarding the pneumonia of whoopto( 



942 THE SPECIFIC INFECTIOUS DISEASES. 

lesion ; if the latter, there is usually meningeal haemorrhage. This is to 
be suspected if there are continued convulsions for several hours, with 
general rigidity or hemiplegia. 

Disturbances of the sight are not infrequent in severe cases ; usually 
these are transient, but there may be blindness lasting two or three 
days or even weeks. The transient symptoms most likely depend upon 
circulatory changes in the brain during the paroxysm, while those which 
last for two or three weeks are probably due to meningeal haemorrhage. 
Disturbances of hearing are rare. The different forms of paralysis occur- 
ring with pertussis may likewise be transient or permanent. They are to 
be explained in the same way as the disturbances of the special senses. 
The most common form is hemiplegia. 

Albuminuria is not infrequent, being found in 66 of 86 examinations 
by Knight. The quantity of albumin is rarely large, and it may be ac- 
companied by a few hyaline casts. Both are probably the result of circu- 
latory disturbances in the kidney. Other complications of pertussis are 
hernia, prolapsus ani, and ulcer of the frenum linguae. 

Diagnosis. — In the early part of the catarrhal stage it is impossible to 
make a diagnosis ; there is no way by which the disease can be distin- 
guished at that period from an ordinary cough ; but after a week the 
gradual increase in severity in spite of treatment, and the fact that the 
cough becomes more and more paroxysmal, and that it is accompanied by 
vomiting and suffusion of the eyes, should make one strongly suspect per- 
tussis. If the disease is prevalent, the diagnosis may be regarded as certain 
when these symptoms are reached, even without the typical whoop. Cases 
which present the greatest difficulty in diagnosis are those of a mild type, 
where, perhaps, without ever having a typical paroxysm, a child who has 
been exposed to pertussis coughs for a number of weeks. Under these 
circumstances it may be impossible to say, even at the close of the attack, 
whether it was or was not pertussis; but if a child has no fever and 
no physical signs of bronchitis, and has been exposed to the disease, the 
probabilities are strong that a severe cough which continues six or eight 
weeks, and upon which ordinary treatment has little or no effect, is per- 
tussis. 

The diagnosis is difficult also in early infancy, for at this period every 
cough is likely to show more or less of a spasmodic character, and there 
may be occasionally heard a fairly typical whoop in the course of an ordi- 
nary attack of bronchitis. This is to be compared to the laryngeal spasm 
which occurs with a mild attack of catarrhal laryngitis. Abortive cases 
also present difficulty in diagnosis. I have seen in a single family three 
children with pertussis of typical duration and severity, and a fourth child 
suffering from a cough, which lasted but two weeks, and in whom the 
whoop was heard only for one day. If such cases occurred by themselves, 
it would be impossible to make a positive diagnosis. 



PERTUSSIS. 943 

Irritation of the pneumogastric or recurrent laryngeal nerve from en- 
larged tracheal or bronchial lymph nodes, whether of a simple or tubercu- 
lous character, may give rise to a spasmodic cough, which in certain cases 
maybe indistinguishable from whooping-cough. The prolonged duration 
of these cases is sometimes the only diagnostic point; but the paroxysms 
are usually not so severe as in true pertussis, and the course is generally 
less typical. 

Prognosis. — The most important factor in the prognosis of the disease 
is the age of the patient. After the fourth year it is indeed rare that 
either a fatal result or serious complications are seen ; but during infancy, 
and particularly during the first year, there are few diseases more to be 
dreaded. This is especially true on account of the connection of whoop- 
ing-cough with the three most fatal conditions of infantile life — broncho- 
pneumonia, diarrhoeal diseases, and convulsions. Fully two thirds of the 
deaths from whooping-cough occur during the first year of life. The 
prognosis is very much worse in infants of the first three months than in 
those who are older and consequently have more resistance. It is better 
in the summer than in the winter, because broncho-pneumonia is then 
frequent. It is particularly bad in delicate infants, in those who are rachitic, 
in those who are prone to attacks of bronchitis, in those who have suffered 
previously from pneumonia, and in those with a strong tendency to tuber- 
culosis. 

The exact mortality of whooping-cough it is difficult to state in 
ures. During the first year of life it is probably not far from twenty-five 
per cent, although it diminishes rapidly after this time. In foundling 
asylums and hospitals for infants it is to be ranked among the most fatal 
diseases, and in some epidemics the mortality in such institutions is as high 
as fifty per cent. 

Fully two thirds of the deaths during whooping-cough are from 
broncho-pneumonia; the next most frequent cause is diarrhoaa] 
Convulsions may be the mode of death in either of the above conditions, 
or may occur apart from them. During the firsl year, death often results 
from marasmus, the child having been reduced by the prolonged dia 
Occasionally death is due to asphyxia following a severe paroxysm, to 
intracranial haemorrhage, or to general emphysema 

As a predisposing cause of tuberculosis, pertu econd only to 

measles. In both diseases tuberculosis develops in much the Bame waj 
and from much the same causes (p 922). 

Prophylaxis.— Pert u Bsis is a contagious disease, and a ohild suffering 
from it should be isolated from other children wherever thi ible. 

Children with pertussis should never he allowed to attend school, and 
needless exposure should always he avoided. 

Young infants, delicate children, and those with a predisposition to 
tuberculosis, should be most carefully protected against 



944 ™ E SPECIFIC INFECTIOUS DISEASES. 

is in them chiefly that the disease is likely to be serious. As it is from 
the patient that the disease is nearly always contracted, there does not exist 
the same necessity for the fumigation and disinfection of apartments as 
after other contagious diseases. In institutions, however, this should 
always be practised, and in private houses if the room is subsequently to 
be occupied by an infant. 

It is as undesirable as it is impossible to confine a child with pertussis 
to a single room during the attack ; all those persons for whom exposure 
would be dangerous should therefore be sent away from the house. Quar- 
antine should continue on the average for six weeks, or until the spas- 
modic stage is over. 

Treatment. — General measures. — It is extremely important that chil- 
dren should have plenty of fresh air throughout the attack. It is a 
matter of common observation that they have fewer paroxysms while out 
of doors than in the house, and that the paroxysms are very much more 
frequent when children are confined in close rooms. They should be kept 
in the open air as much as possible during the day, in pleasant weather, 
and even on unpleasant days the windows should be freely opened. If a 
child's temperature is above 100° F., he should not be sent out, but may 
have fresh air in the room. In all cases it is important to have the win- 
dows freely opened at night, unless bronchitis or broncho-pneumonia is 
present. 

A change of air is desirable for cases in which the cough is unduly 
prolonged. A warm place at the seashore is one which is most likely to 
be beneficial. The improvement during a sea voyage is sometimes very 
marked, and it surpasses even a residence at the seashore. 

The rooms occupied by children suffering from pertussis should be 
frequently changed, thoroughly aired, and, when possible, occasionally 
fumigated. This change of rooms, clothing, bedding, etc., sometimes 
exerts a marked influence on the course of very prolonged attacks, the 
inference being that continued re-infection takes place. Such a change 
should be made twice a week, and it is of special importance in hospitals, 
where many children quarantined in a ward seem to cough interminably. 

Vomiting and indigestion are both so frequent that feeding becomes 
at times very difficult. In most cases it is necessary to repeat the meal in 
a short time, if the first one has been vomited in consequence of a severe 
paroxysm. Children over two years old should in all such cases be kept 
upon a fluid diet, chiefly of milk. For infants, milk should be diluted, 
and in many instances it must also be partially peptonized. Any medi- 
cation which causes disturbance of the stomach must be omitted. In 
severe cases, on account of the inability to retain a proper amount of 
food, the child's strength should be kept up by the use of alcoholic 
stimulants. 

Local treatment. — This may be in the form of insufflations of powder 



PERTUSSIS. 945 

into the nose, local applications to the larynx by a spray or swab, and 
inhalations. 

The first two methods have been advocated, in the belief that the 
cough is due to an infections catarrh having its seat in the nose or 
larynx. For insufflation, quinine or benzoic acid is preferred, mixed 
with some finely divided, inert powder, such as bicarbonate of sodium, 
talcum, or coffee ; these are used with the powder insufflator once or 
twice daily. Local applications to the larynx may be made by means 
of the spray or swab. Eesorcin and carbolic acid, each in a one-per-cent 
solution, are most used. These applications are made once or twice 
daily. I have not seen from any of the above methods the beneficial 
results claimed, and I believe them to have been exaggerated. The appli- 
cation of cocaine to the larynx, although highly recommended, should 
never be employed in young children on account of the danger of poi- 
soning. 

Inhalations are of much more value. They are useful to modify the 
catarrh by allaying irritation, facilitating the expulsion of the mucus, and 
possibly as antiseptics. Those most employed are carbolic acid, creoe 
and cresoline. In my experience creosote is by far the best. These sub- 
stances may be used dropped upon cotton in a respirator, or vapourized 
over an alcohol lamp (page 58), or cloths may be dipped in solutions and 
hung in the patient's room. In using carbolic acid the possibility of 
absorption should not be forgotten, and the urine should be watched. 
In paroxysms of great severity, inhalation of chloroform may be required 
as the only means of warding off convulsions or preventing dangerous 
asphyxia. 

Internal medication,— Qi the innumerable drnge which have been 
recommended for this disease, three possess undoubted advantages over 
all others— viz., quinine, belladonna, and antipyrine. Quinine is best 
given to young children in an aqueous solution of the bisulphatej it 
should be given in full doses, from eight to ten grains daily to an infant 
under two years, and from fifteen to twenty grains to children from 
two to four years old. The only objection to quinine is its bend. 
to upset the stomach; if it causes vomiting the dose must be reduced 
or the drug discontinued. It will usually be found more successful in 
children over, than in those under, four years. I rar.lv attempt to 

it in infants. 

Belladonna may be used in the form of the fluid extracl or atropine. 
It is important to begin with a small dose and gradually increase both its 
frequencvand size until the physiological effects of thedrugare produ 
To an infant two years old, half a minim of the fluid 
given every four hours as an initial dose, gradually increasing 
two hours; if atropine is used, gr. ,»,„ may be given in tl 
Although belladonna usually has a decided influence in reducing both 



946 THE SPECIFIC INFECTIOUS DISEASES. 

frequency and the severity of the paroxysms, it causes so many unpleasant 
symptoms that it is difficult to continue its use for a long period. 

Antipyrine has been in my hands more satisfactory than either quinine 
or belladonna. It may be used with safety even in young infants in con- 
siderably larger doses than are ordinarily employed. For a child six 
months old the initial dose should be one grain every three hours ; later, 
this may be given every two hours, and sometimes even more frequently. 
For a child two years old the initial dose should be two grains every four 
to six hours, gradually increased if necessary up to two grains every two 
hours. The frequency of the dose will depend upon the severity of the 
case. In the event of the development of pneumonia the antipyrine 
should be discontinued. 

With bromoform and other newer remedies I have had much less suc- 
cess than with those referred to. Nearly all drugs which allay nervous 
irritability have a certain amount of effect in controlling the paroxysms 
of pertussis ; chloral and trional are often useful where the night attacks 
are so severe as to prevent sleep. Better results are sometimes obtained 
from a combination of the bromide of sodium with antipyrine than from 
the latter given alone. I do not believe that any form of internal medica- 
tion or local treatment shortens pertussis ; but, inasmuch as the disease is 
self-limited, great benefit to the patient results from the reduction of the 
number and the diminution of the severity of the paroxysms. 

In establishing the value of any method of treatment, it should be 
remembered that the number of cases in which the disease is considerably 
shorter than the average is large, and also that almost any method of treat- 
ment if employed after the attack has reached its height will be thought 
beneficial, as the natural tendency is then to improve. The value of any 
particular line of treatment is to be judged in a given case only by its 
effect in reducing the number and severity of the paroxysms. This ought 
to be evident in the case of drugs within two or three days, and can only 
be determined by keeping a careful record of the number of severe par- 
oxysms day and night. No drug succeeds equally well in all cases. 

In a mild case, where the number of severe paroxysms does not ex- 
ceed eight or ten during the day, where there is no vomiting and the gen- 
eral health is not affected, it is not usually advisable to continue the 
administration of any drugs throughout the disease. A single dose of 
antipyrine or phenacetine at night may be all that is necessary. All cases 
in infants must be watched with great care and the parents warned of the 
possible dangers which may supervene suddenly, even in the course of 
mild attacks. For severe cases antipyrine should be given to diminish the 
frequency and the severity of the paroxysms and inhalations of creosote 
used if much catarrh is present. All the fresh air possible should be 
allowed. For older children the same plan of treatment may be followed, 
or quinine or belladonna may be substituted for the antipyrine. 



MUMPS. 947 

As these drugs are given solely for the purpose of diminishing the 
frequency and severity of the paroxysms, their continuous use should be 
deferred until the symptoms are sufficiently severe to greatly disturb the 
child, the benefit at this period being more striking than if they are begun 
early and used continuously. 



CHAPTER VII. 

MUMPS. 

Synonym : Epidemic parotitis. 

Mumps is a contagious disease characterized by swelling of the parotid, 
and sometimes of the other salivary glands, with constitutional symptoms 
which are usually mild. Both severe complications and a fatal termina- 
tion are extremely infrequent. The disease is not a very common one, 
and general epidemics are rare. 

Pathology and Lesions. — The contagious character, definite incuba- 
tion, and typical course, stamp the disease as a general one due to a spe- 
cific poison, probably a micro-organism, whose nature is as yet unknown. 
It is probable that infection takes place through the salivary ducts. 

The precise nature of the changes in the gland is still a matter of 
dispute, as opportunities for pathological examination are very rare. Prom 
existing evidence it would appear that the gland substance is first involved, 
and afterward the surrounding connective tissue. The gland is the Beat 
of an intense hyperaemia and oedema; the walls of the salivary duets are 
swollen, and the ducts are obstructed. While the primary disease does 
not tend to excite suppuration, pyogenic germs may occasionally gain 
entrance and an abscess form; but this is to be regarded as a rare, acci- 
dental infection. 

In the great proportion of cases the parotids alone are affected, al- 
though the same changes are occasionally found in the other salivary 
glands. There are no other essential lesions of the disease, those which 
are found depending upon complications. 

Etiology.— Mumps is spread by contagion, close contact being usually 
required to communicate the disease, although it is known to have been 
carried by a third party and even by clothing. The BUSCeptibility of chil- 
dren to the poison of mumps is much less than i< the case with the other 
contagious diseases, so that only a Bmall number of those who are exp 
take the disease. The greatest predisposition is between the fourth and 
fourteenth years. Infants are rarely affected, although a case in a child 
three weeks old is vouched for by so good an observer as Demme. 

Mumps is contagious from the beginning of the symptoms Two 
have come under my notice in which the disease was communicated 



948 THE SPECIFIC INFECTIOUS DISEASES. 

before any swelling was seen. It is impossible to fix with certainty the 
duration of the infective period. The disease is undoubtedly communi- 
cable for several days after the swelling has subsided ; and for safety a case 
should be isolated for three weeks from the beginning of symptoms, or at 
least ten days after the swelling has disappeared. 

Incubation. — In forty-eight collected cases in which the incubation 
was definitely determined, it varied between three and twenty-five days. 
It was less than fourteen days in only four cases, and in twenty-six of the 
forty-eight cases it was between seventeen and twenty days. In three 
cases of my own in which it could be definitely fixed, the incubation was 
nineteen days in one and twenty days in two cases. The average period of 
incubation, then, may be stated to be from seventeen to twenty days. 

Symptoms. — In the milder cases the local symptoms are the first to at- 
tract attention ; in those which are more severe there are frequently pro- 
dromal symptoms of from twelve to forty-eight hours' duration, — anorexia, 
headache, vomiting, pains in the back and limbs, and fever. Soltmann 
has reported a case ushered in by convulsions. The initial temperature 
in a mild attack is 100° to 101° F. ; in a severe one, from 102° to 104° F. 

Of the local symptoms, the pain usually precedes the swelling; it is 
increased by movement of the jaws, by pressure, and sometimes by the 
presence of acid substances in the mouth. It is usually referred to the 
posterior part of the jaw just below the ear. The swelling may begin 
simultaneously in both parotids, but more frequently one side is involved 
a day or two in advance of the other. It usually reaches its maximum on 
the third day, often on the second, remains stationary for two or three 
days, and then subsides gradually. The degree of swelling varies with the 
severity of the attack. When it is marked, the patient presents a ridicu- 
lous appearance and is scarcely recognisable ; it fills the lateral region of 
the neck between the jaw and the sterno-mastoid muscle and extends 
forward upon the face to the zygomatic arch, so that the centre of the 
tumour is usually the lobe of the ear. The other salivary glands may 
swell simultaneously with the parotids, or several days later, even after the 
parotid tumour has disappeared. Occasionally swelling of the submaxil- 
lary or the sublingual glands occurs before that of the parotid, and in rare 
instances these may be the only glands affected. 

As a rule, the parotid of both sides is involved. Of 282 cases both 
sides were affected in 215. When one side alone is involved, it is the left 
a little more frequently than the right. The interval between the swell- 
ing of the two sides may be a week, or even five or six weeks, but usually 
it is only two or three days. 

The salivary secretion is usually very much diminished, and the dry 
mouth causes great discomfort. An exceptional instance has been re- 
ported by Simon, in which a distressing salivation occurred, the secretion 
amounting to six or eight ounces daily. 



MUMPS. 949 

Although as a rule the patient is not seriously ill, mumps may in rare 
cases produce most alarming and even dangerous symptoms. The tem- 
perature may for several days reach 104° F. or more, deglutition may be 
extremely difficult, pressure on the jugular veins may lead to venous hyper- 
emia of the brain, causing headache and sometimes delirium : there is 
sometimes great prostration and the symptoms of the typhoid condition. 
These severe attacks are nearly always in children over twelve years old. 

The constitutional symptoms of mumps usually last from three to five 
days; the swelling continues on an average a little less than a week. If 
the case has been a severe one, slight swelling may continue for two weeks 
or even longer. Relapses, in which the opposite side from the one first 
affected is involved, are quite frequent, occurring iu about ten per cent of 
the cases. 

Complications and Sequelae. — In childhood the complications are few 
and usually unimportant ; but in adolescence they are occasionally serious. 
Orchitis is exceedingly rare in childhood ; of 230 cases observed by Billiet 
and Barthez, this was seen in but 10, and only 3 of these cases were under 
fifteen years, and no case under twelve years old. When orchitis occurs it 
is generally toward the end of the second or the beginning of the third 
week ; it is usually marked by an accession of fever, sometimes by a chill ; 
if severe, nervous symptoms may be present. The local symptoms do not 
differ from those of an ordinary attack of orchitis. The body of the tes- 
ticle and not the epididymis is generally affected. The acute symptoms 
continue for three or four days, and the entire duration is about a week ; 
although the testicle is often enlarged for some time afterward, ami 
atrophy of the organ may follow. 

In females, congestion and swelling of the breasts, ovaries, Or labia 
majora may occur ; and, although they are all rare, they have been ob- 
served even in young children. 

Nephritis has in a few instances followed mumps, sometimes coming 
on as late as four or five weeks after the attack. Single cases have been 
reported by Croner, Isham, Henoch, and others. Nervous sequelae are 
more frequent, but even these are rare. .lalTrey has reported B 
multiple neuritis with typical symptoms, occurring three weeks after an 
attack. Facial paralysis three weeks after mumps has been reported by 
Hillier, apparently due to an extension of inflammation from the -land 
to the seventh nerve. 

Pearce* has colleeted an interesting series of forty oases of dei 
following mumps, in which there was no sign of otitis, the symptoms 
coming on suddenly with vertigo, a Btaggering -ait. and often with vomit- 
in^ 'in most of the eases the deafness WW unilateral and tie losfl ol 
hearing was permanent. Tim can- assigned waa dises f the auditory 



■• Manchester Chronic! 



950 THE SPECIFIC INFECTIOUS DISEASES. 

nerve, the seat of the trouble being in the labyrinth. Toynbee has re- 
ported an instance of haemorrhage into the labyrinth. Otitis media is 
rarely seen. 

Suppuration of the parotid glands occurs in about one per cent of the 
cases, and is probably due to accidental infection. Gangrene and slough- 
ing of the parotid were observed twice by Demme in 117 cases, both of 
which proved fatal. Pneumonia, meningitis, endocarditis, and pericar- 
ditis have all been observed as complications of mumps, although all are 
extremely rare. 

Prognosis. — In the great proportion of cases mumps is a mild disease, 
and terminates in complete recovery in a few days. In young children 
complications are infrequent, and those which occur are rarely severe. 

Diagnosis. — Mumps is most likely to be confounded with acute swell- 
ing of the cervical lymph nodes. In a parotid swelling, the lobe of the 
ear is near the centre of the tumour, which extends backward to the 
sterno-mastoid muscle and forward upon the face as far as the zygomatic 
arch, embracing the angle and ramus of the jaw. 

A swollen lymph node is usually entirely below the ear and behind the 
jaw, never extending upon the face. The tumour is generally smaller 
and more circumscribed if only a single node is involved, and it comes on 
much more slowly than does mumps. When only the submaxillary or 
sublingual glands are affected, the diagnosis from swollen lymph nodes is 
sometimes impossible except by the course of the disease. Mumps is 
characterized by the rapidity with which the swelling occurs, and by its 
relatively short duration. 

Treatment. — The disease is self-limited and the individual symptoms 
rarely distressing, so that in most cases very little treatment is required. 
If constitutional symptoms are present the patient should be kept in bed, 
and if there are none he should be confined to the house. The gland 
should be protected by cotton or spongio-piline, and if the pain is severe 
heat should be applied or the gland painted with belladonna. The diet 
should be liquid, on account of the pain produced by mastication. The 
mouth should be kept clean by the use of some antiseptic mouth- wash. 
The general symptoms and complications are to be treated according to 
the indications in the individual cases. Cases of mumps occurring in 
schools or institutions should be quarantined for three weeks, and in 
private practice where there are susceptible persons. Fumigation and 
disinfection after an attack are unnecessary. 



DIPHTHERIA. 951 



CHAPTER VIII. 

DIPHTHERIA. 

Until within the last few years it has been customary to clasc 
diphtheria all diseases characterized by the production of a false mem- 
brane upon the mucous membranes of the throat or air passages. Bacte- 
riological study of these cases has yielded results so uniform that we are 
now able to separate them into two groups : In one, there has been demon- 
strated the constant presence of the Klebs-Loeffler bacillus — the Bacillus 
diphtheria ; this group includes cases formerly classed as primary diph- 
theria, and also certain others such as primary membranous laryngitis and 
rhinitis, the pathology of which has been the subject of much dispute. 
In the other group the Klebs-Loeffler bacillus is absent ; this group in- 
cludes most of the membranous inflammations of the throat which occur 
as complications of measles and scarlet fever, and many primary 
such inflammations affecting only the tonsils or the tonsils and pharynx, 
and formerly regarded by some as croupous tonsillitis, by others as mild 
or doubtful diphtheria. The form of bacteria which has usually been 
found in these inflammations which simulate diphtheria, is the streptococ- 
cus pyogenes, occasionally the staphylococcus. In the following pages the 
term diphtheria will be limited to those cases in which the Klebs-Loeffler 
bacillus is present, the others being grouped under the head of false or 
pseu do- diph theria. 

Diphtheria may then be defined as an acute, specific, communicable 
disease due to the bacillus of Klebs and Loefrler. It is usually charac- 
terized by the formation of a false membrane upon certain mncoufi mem- 
branes, especially those of the tonsils, pharynx, nose, or larynx, lake 
other pathogenic organisms, however, this germ acts with varying in- 
tensity, and may cause inflammation of all degrees of severity, from a mild 
catarrhal angina to the most serious membranous inflammation; but to 
all alike the term diphtheria should be applied. In its mil i form it may 
be almost without constitutional symptoms ; but in re form it is 

attended by great general prostration, cardiac depression, and ana-mi;!, it 
is frequently complicated by pneumonia and nephritis, and it may be fol- 
lowed by localized or general paralysis; it then constitutes one of the 
diseases most to be dreaded in childhood. While, therefore, there are now 
included under the term diphtheria many :imrl\ Q< 

as such, there are excluded many others which somewhat resemble it 
clinically, but in which the bacillus of diphtheria is absent 

Etiology.— 77 < Bacillus Diphtheria.— ThiB was firsl 
Klebs in 1883, and during the following year it was isolated by Loeffler 



952 THE SPECIFIC INFECTIOUS DISEASES. 

and shown to be pathogenic. Little was added to this discovery until 
1888, but from that time until 1891 very extensive observations were made 
in France, Germany, and America,* all confirming the early conclusions 
of Loeffler. By 1891 all the conditions, says Welch, had been fulfilled to 
demonstrate that this bacillus was the cause of diphtheria, — viz., (1) its 
constant presence ; (2) its isolation in pure culture ; (3) the reproduction 
of the disease in animals by inoculation with pure cultures ; (4) the find- 
ing of a similar distribution of the bacilli in the original and in the ex- 
perimental disease. 

The bacillus of diphtheria varies considerably in size and shape even 
in the same culture. Its length is from 1-5 to 6-5 micro-millimetres ; its 
diameter, from 03 to 0-8 micro-millimetres. In a specimen it occurs 
singly or in pairs, sometimes in chains of three or four ; the bacilli may 
lie parallel, but frequently two form an acute or an obtuse angle (Plate 
XVIII, 3, 4, and 5). They are straight or slightly curved, and are some- 
what swollen or club-shaped at their ends. The bacilli have no spores, 
but contain highly refractile bodies, which cause them to stain peculiarly. 
With alkaline methyl blue (Loeffler's stain) they stain in a very charac- 
teristic way ; not uniformly, but the oval bodies in the central parts or in 
the extremities of the bacillus, stain more deeply than the rest of the 
protoplasm. This difference is not seen in the old cultures which stain 
with difficulty (Park). 

The best culture medium is Loeffler's blood-serum. f After ten or 
twelve hours, at a temperature of about 100° F., the colonies (Plate XVIII, 
1 and 2) appear slightly elevated, of a white or grayish colour, with 
rounded but generally irregular borders. They may increase to one 
fourth of an inch in size ; and although the early colonies are about the 
same size as those of the streptococcus, the later ones are larger. They 
do not liquefy the blood-serum. 

Distribution and mode of communication. — Diphtheria prevails epi- 
demically, endemically, and sporadically. In most large cities it is en- 
demic, occasional cases occurring throughout the year, with periods in 
which outbreaks of considerable severity are observed. In the country it 
prevails chiefly as an epidemic. The disease is often introduced into re- 
mote districts in some inexplicable manner, and before its nature is 
recognised a large number of persons have been exposed, and an epidemic 
results.]; 

* For a summary of the literature upon this subject see Welch and Abbott, Johns 
Hopkins Hospital Bulletin, February and March, 1891 ; Prudden, New York Medical 
Record, April. 1891 ; Park, New York Medical Record, July and August, 1892. 

f Blood-serum two thirds, nutrient bouillon one third, glucose one per cent. 

X The following is an example of the way in which diphtheria may be introduced: 
In the country branch of the New York Infant Asylum, consisting of a somewhat iso- 
lated community of about five hundred persons, chiefly children, there had been no 



DIPHTHERIA. 953 

Diphtheria does not arise de novo. Every case has its origin in a pre- 
vious case either directly or remotely. The bacilli may enter the bodv 
through the inspired air ; they may be taken into their mouth upon toys 
or other articles upon which they have lodged, or by kissing, and some- 
times accidental inoculation occurs. As a rule, the bacilli first gain a 
foothold upon the mucous membrane of the tonsils, nose, or larynx. 

Direct infection is the cause in the great majority of the cases. There 
is no proof that the bacilli are contained in the breath of a person Buffer- 
ing from the disease. They are discharged in great numbers in the saliva 
and mucus from the mouth and nose, and in pieces of membrane which 
are coughed up ; they are not present in the urine or faeces. The most 
contagious cases are those of pharyngeal diphtheria of severe type and 
long duration, chiefly on account of the amount of discharge which 
accompanies them. The cases that are least contagious, and for precisely 
opposite reasons, are those in which the membrane is limited to the larynx 
and lower air passages. 

Direct infection may occur from persons convalescent from diphtheria, 
whose throats still contain virulent bacilli, or from persons Buffering 
from a mild form of the disease, which is not recognised as diphtheria. 
In the latter way it is often spread in schools. It has been shown that a 
person may harbour virulent bacilli in his nose or throat, and may even 
communicate the disease to others, without himself Buffering from diph- 
theria at any time. 

The length of time during which a patient with diphtheria may con- 
vey the disease to others is somewhat uncertain. Transmission is possible 
so long as virulent bacilli remain in the throat ; these are frequently found 
two weeks after the membrane has disappeared and the patient is regarded 
as entirely well, and in a few cases they are found live or six week 

longer after recovery. 

Indirect infection is not uncommon, and may occur from the bed or 
clothing of the patient, from the carpet, furniture wall-paper or bang 
of the room, from toys or picture-books, from dishes, feeding-bottles, or 
drinking-cups, from swabs and brushes nsed f«>r local applications to the 
throat, from spoons and tongue-depressors, and from surgical instruments 
with which tracheotomv or intubation baa been done. Diphtheria maybe 
carried by a third person, hut rarely except by one who has been in , 



case of diphtheria for several years until 1887. The first case »a* 01 f membranous 

laryngitis, proving rapidly fatal in two days. A, autopsy, membrane was found only 

in the larynx. The case was regarded at that time as evident f theexistem fa 

primary non-diphtheritic membranoua croup. In the eour I the next few v. 

there developed a numberof cases of typical diphtheria. On h 

covered that the nurse who had charge of the child first affected, had been a fe* w 

before in attendance upon a cs f diphtheria, Duringthefl 

of diphtheria occurred in the institution every year. 



954 THE SPECIFIC INFECTIOUS DISEASES. 

contact with the patient — either the physician or nurse. The frequency 
of diphtheria in physicians' families bears witness to the great danger of 
infection in this manner. 

Bacilli may retain their virulence for an indefinite period. Both Park 
and Loeffler found cultures in blood-serum to be virulent after seven 
months ; Roux and Yersin, bacilli in dried membrane to be virulent after 
twenty weeks ; and Abel, upon a child's toy after five months. 

Domestic animals may in rare instances be carriers of infection, and 
in the case of pigeons, at least, they may themselves suffer from the dis- 
ease. Diphtheria has been repeatedly spread by milk, but very rarely 
through the contamination of a water supply. Bad drainage, defective 
sewerage, and decomposing organic matter are occasionally associated with 
outbreaks of diphtheria, these furnishing conditions favourable to the 
development of the bacilli ; but apart from the presence of the bacilli 
they are incapable of producing the disease. 

Predisposing causes. — Local conditions in the throat influence very 
largely the occurrence of diphtheria. An important predisposing cause 
is the existence of a chronic catarrhal inflammation of the mucous mem- 
branes of the nose and throat, so frequently found in children suffering 
from adenoid growths of the pharynx or enlarged tonsils. These adenoid 
growths, the tonsillar crypts, and the cavities of carious teeth, may harbour 
the bacilli for a considerable time both before and after an attack. The 
condition of these membranes in other acute infectious diseases furnishes 
a marked predisposition to diphtheria. This is most striking in the case 
of measles and scarlet fever; it is seen less frequently in typhoid fever 
and influenza. Children with very sensitive mucous membranes, such as 
those reared in institutions or in tenement houses, are peculiarly sus- 
ceptible. Infection through a healthy mucous membrane, if not impos- 
sible, is certainly very unlikely. 

The two sexes are about equally liable to the disease. Children under 
ten are much more often affected than those who are older, the greatest 
susceptibility as regards age being between the second and fifth years. 
Of 14,688 deaths occurring in New York from diphtheria during ten 
years, the ages were as follows (Billington) : 

Under one year 1,214 

One to five years 9,622 

Five to ten years 3,212 

Ten to fifteen years 311 

Over fifteen years 329 

14,688 

While diphtheria is seen throughout the year, it is rather more fre- 
quent during the cold than the warm months. Of 18,688 deaths occur- 
ring in New York from diphtheria during thirteen years, there were 



DIPHTHERIA. 955 

10,769 from October to March, inclusive, and 7,919 from April to Sep- 
tember, inclusive (Bos worth). 

The incubation of diphtheria is short. In most of the cases in which 
it could be definitely traced it has been between two and five days. It is 
shorter when the disease is epidemic, when the patient is very susceptible, 
when the local conditions in the mucous membranes are favourable, and 
when the type is virulent. The virulence varies much in different ci 
and in different seasons, and while it is frequently true that persons in- 
fected from a mild case have a mild type of the disease, and those infected 
from a malignant one a severe type, there is no certainty that such will be 
the sequence. Dr. W. H. Park informs me that, out of many hundreds 
tested in the laboratory of the New York Health Department, by far the 
most virulent type of the bacillus was obtained from the throat of a boy 
who had what was clinically regarded as a very mild form of tonsillar 
diphtheria. 

Second attacks of diphtheria, while more frequent than those of 
measles or scarlet fever, are relatively rare. It seems to be established by 
recent observations that the immunity conferred by one attack of diph- 
theria is of comparatively short duration, amounting probably to a few- 
months only. In my own experience, however, I can recall but very few 
instances of second attacks. R. W. Parker (London) believes the protec- 
tion afforded by one attack to be quite as complete as that of measles <>r 
scarlet fever. 

Lesions. — The essential lesions of diphtheria consist not in the produc- 
tion of a membrane, but, as long ago pointed out by Oertel, and more 
recently by Babes, Sidney Martin, and others, in certain acute degenerative 
changes in the cells of the body caused by the diphtheria toxines. These 
changes are seen particularly in the epithelial cells of the affected mucous 
membranes, the heart muscle, the kidney, the liver, the peripheral nervous 
system, the spleen, and the lymph glands; the most characteristic being 
those of the nerves and the liver. There are other lesions which are the 
result of the action of other organisms, especially the streptococcus pyo- 
genes and the pneumococcus, either alone, together, or in conjunction 
with the diphtheria bacillus. The most important lesions due to these 
organisms are broncho-pneumonia and nephritis; but there may be found 
in the blood, and in many of th.- organs of the body, the evidences -f the 
invasion of these bacteria i.e.. a Btreptocoocus septicaemia, less frequently 
a general pneumococcus infection. 

Distribution of the <Hi>litl<»ri« bacillus in the body.- Unlike many 
other pathogenic organisms, the diphtheria bacillus is not widely dis- 
tributed throughout 1 the body. It is found in -rent cumbers on the 
surface of the affected mucous membranes and in the false membrane 
itself, particularly in its superficial portion, hut it docs not invade deeply 
the subjacent structures. It is only exceptionally found in the blood and 



956 THE SPECIFIC INFECTIOUS DISEASES. 

in distant organs, and then in such small numbers that its presence is 
rarely discovered except by cultures. 

The diphtheria toxines. — The wide-spread effects seen in diphtheria are 
due to the action of certain substances called toxines which the diphtheria 
bacillus produces during its growth on mucous membranes. The toxines 
have been studied especially by Eoux and Yersin, Brieger and Fraenkei, 
and have been called tox-albumins. They are very diffusible, readily 
entering the lymphatic circulation and the blood, and through these 
channels may affect the entire body. It has been shown by Welch and 
Flexner and others that in susceptible animals there may be produced by 
the injection of the toxines all the characteristic lesions of diphtheria 
except the membrane, as well as the essential symptoms of the disease, 
even including paralysis. For the production of the membrane living 
bacilli are required. 

" Catarrhal " diphtheria. — It has been already stated that a membrane 
is not always present in inflammations excited by the diphtheria bacillus. 
The routine practice of making cultures from diseased throats has estab- 
lished the fact that in a large number of cases catarrhal inflammation may 
be the only result of diphtheritic infection. To the naked eye there may 
be only the ordinary changes of a catarrhal inflammation of a mucous 
membrane ; but even in such cases Oertel found the characteristic degen- 
erative changes in the epithelial cells. These, of course, vary in degree 
with the severity of the process. 

The diphtheritic membrane. — The membrane is most frequently seen 
upon the mucous membrane of the tonsils, soft palate, uvula, pharynx, 
nose, larynx, trachea, and bronchi ; less frequently upon the mouth, lips, 
oesophagus, conjunctivae, middle ear, stomach, and genital organs. It may 
also affect fresh wounds, notably a tracheotomy wound, or any abraded 
cutaneous surface. The gross appearance of the membrane varies greatly 
(Plate XVII). It is most frequently of a gray or mouse-colour, but it 
may be pearly white, yellow, green, and sometimes almost black. It is 
composed of fibrin, cells, granular matter, and bacteria. Its consistency 
varies with the relative proportions of the different elements. When made 
up chiefly of fibrin it is firm and retains its form, often being discharged 
as a complete cast of the nose, larynx, or trachea. When the amount 
of fibrin is small the membrane is soft, friable, and sometimes granular. 
It is more closely adherent upon the mucous membranes covered with 
squamous epithelium, as in the pharynx and upper air passages, than upon 
those covered with columnar and ciliated epithelium, as in the lower air 
passages. 

The microscopical examination shows the fibrin to be sometimes gran- 
ular, but usually in the form of a network, inclosing in its meshes small 
round cells and epithelial cells in various stages of degeneration. On the 
surface and in the superficial layer there is usually found quite a variety 



DIPHTHERIA. 



957 



of bacteria including diphtheria bacilli. Beneath this is a cellular layer 
containing little or no fibrin, in which also the diphtheria bacilli arc usu- 
ally found. In the deepest parts of the false membrane and in the mucous 
membrane itself they are few in number or absent. 

Characteristic changes which are similar in all the affected mucous 
membranes are found in the epithelial cells. The cells undergo marked 
proliferation and infiltration with leucocytes ; they show also degenerative 
changes in their protoplasm and fragmentation of their nuclei, which 
result in the formation of granular masses of necrotic substance. The 
infiltration with small round cells is variable in degree in the different 
mucous membranes ; in some it extends deeply into the submucous and 
even the muscular layers, while in others it is very superficial. Marked 
evidences of cell death are seen also in the cells infiltrating the deeper 
layers. In places the epithelium is detached, in others the line bet* 
the false membrane and the granular mucous membrane is Bcarcely dis- 
tinguishable. 

The seat and the distribution of the membrane. — This varies bo me what 
with the age of the patient, the season, and the peculiarity of the epi- 
demic. In the following table are given some figures from the records of 
the New York Infant Asylum. These cases were taken consecutively, and 
did not belong to a single epidemic : 



Above the larynx 
(63 eases). 

Not above the 

larynx 

(10 cases). 



f Tonsils only 81 

< Pharynx or pharynx and tonsils 1^ 

I Pharynx and nose or rhino-pharynx 

( Larynx only 

! Larvnx and trachea 



18 - 

(i •• 



Larynx, trachea, and large bronchi 



Both above and 



below the larynx "j «• 



i 'Larynx, trachea, large and to smallest bronchi 

f Pharynx and larynx 

Pharynx, larvnx, and trachea 

Pharynx, larynx, trachea, and large bronchi 

Pharynx, larynx, trachea, large and t«» smallest bronchi 



(36 cases). 



>se, pharynx, larynx, and t rachi 



Nose, larynx, and trachea 

Pharvnx and trachea (none in larynx) 



8 •• 

I •• 
10 •• 
i case, 

l •• 

l •• 



Pharynx, trachea, and bronchi (none in larynx) t " 

LOO 

All these cases were in young children, - ni of them being under 

two years old. In the firsl group the mortality was 30 percent; in the 
second group, 90 per cent : in the third group, at The lai 

was involved in 42*2 percent of the The location of the membrane 

was determined by autopsies in all the rixty-one fatal cases. Th< 
tendency of the disease in young children to invade the lower air | 
and to extend far into the bronchi when once the larvnx is involved, is also 
shown in a report up<»n eighty-seven autopsies in laryngeal oases mad< 



958 THE SPECIFIC INFECTIOUS DISEASES. 

Norfchrup. In only three was the larynx alone the seat of membrane ; in 
57 per cent the membrane descended into the bronchi, and in 37 per cent, 
to the finest bronchi. All these records are of the pre-antitoxine days. 

An interesting comparison with the figures above given may be made 
with those of Lennox Brown of 1,000 cases, including persons of all ages, 
but mainly, doubtless, children : 

' Fauces (including tonsils) alone 672 cases. 

Above the larynx Nose alone 2 " 

(841, or 84"1 -J Fauces and nose 165 " 

per cent). Mouth or lips alone 1 case. 

Hard palate alone 1 " 

Involving the r Larynx alone 4 cases. 

larynx * (159, or { Larynx and fauces 109 " 

159 per cent). I Larynx, fauces, and nose 46 '' 

The tonsils are the most frequent and usually the earliest seat of the 
diphtheritic membrane ; it may form here a tough, leathery patch, par- 
tially or completely covering and very adherent to them ; or the disease 
may affect only the tonsillar crypts, so that the gross lesion may resemble 
that of ordinary follicular tonsillitis. There is in most cases only moder- 
ate swelling, but it may be so great that the tonsils are in contact. The 
surrounding cellular tissue is infiltrated with inflammatory products. 

The membrane covering the pharynx and uvula is also usually very 
adherent and intimately blended with the mucous membrane. The uvula 
is swollen and oedematous. Membrane may be seen only upon the fauces 
and uvula, or the posterior and lateral pharyngeal walls may be covered 
down to the level of the cricoid cartilage, but generally not below this 
point. If the posterior pharyngeal wall is covered, the membrane is apt 
to extend into the rhino-pharynx, and may fill the entire pharyngeal 
vault, covering the posterior portion of the velum and extending into the 
posterior nares. The adenoid tissue of the vault is a favourite seat, and 
is frequently the part most affected. The amount of infiltration of the 
submucous tissue varies much in the different cases. 

The nose may be involved secondarily to the rhino-pharynx, or infec- 
tion may be through the anterior nares ; if the latter, it is not infre- 
quently the only part involved. Many cases classed as nasal are really 
rhino-pharyngeal. The membrane in the pure nasal cases is usually thick 
and tough and often separates en masse. Both sides are generally in- 
volved, but it may be unilateral. Catarrhal diphtheria of the nose and 
rhino-pharynx is probably more frequent than in any other location. 

The epiglottis is swollen to three or four times its normal thickness, 
and the aryteno-epiglottic folds are oedematous. The anterior surface of 

* These being clinical and not pathological records, the number in which the dis- 
ease extended below the larynx is not given. 



DIPHTHERIA. 959 

the epiglottis is rarely covered by membrane; but its lateral borders and 
posterior surface, and the aryteno-epiglottic folds are involved in most of 
the severe pharyngeal cases (Plate XVII, 0). This lesion is associated 
with pharyngeal rather than with laryngeal diphtheria. 

The lesions which extend most deeply are thus seen in the tonsils, 
uvula, pharynx, and epiglottis. But even here there is very rarely deep 
or extensive sloughing. 

The lesions of the larynx, trachea, and bronchi are similar to the 
above, although much more superficial. The interior of the larynx may 
be completely covered, the membrane coating the true and false vocal 
cords and lining the ventricles of the larynx; or it may extend from 
the epiglottis down to the anterior surface of the larynx, while the pos- 
terior surface is free. The membrane in the larynx is not usually very 
adherent, and it frequently separates and is coughed up in large pi 
or even as a cast. The membrane covering the epiglottis and the 
aryteno-epiglottic folds is very adherent, like that of the pharynx. 
Catarrhal laryngitis is not an uncommon complication of pharyngi ;il 
diphtheria. 

In a considerable number of cases the membrane stops abruptly at the 
lower border of the larynx. In the trachea it is generally loosely attached, 
and often it is found at autopsy entirely separated from the mucous mem- 
brane. It is almost invariably associated with membrane in the larynx. 
Usually the membrane in the bronchi is continuous with that in the 
trachea. Occasionally I have seen the trachea and larger bronchi pae 
overand found membrane only in the larynx and smaller bronchi. A- a 
rule, the bronchi of both sides are affected, and to the same degree. I 
once saw a case of laryngeal diphtheria in which membrane was found 
only in the bronchi of one lung. The above exceptions are to he explained 
as accidents in the mechanical transportation of bacilli. 

The extent of the membrane varies greatly in different cases. \\ ma y 
stop at the bifurcation of the trachea or at the bifurcation of the primary 
bronchi; but if it goes beyond this point it is likely to extend to the 
minutest subdivisions. In the large bronchi, as in the trachea, the mem- 
brane is loosely attached. In the smallest bronchi it i- more adherent, 
and sometimes only to be made out by the microscope. Exceptionally a 
very tough fibrinous membrane forms in the trachea and bronchi, of suf- 
ficient thickness and consistency to be expelled as a cast, reproducing 
almost the entire bronchial tn 

The inflammation of the mucous membrane of the larynx, trachea, and 
bronchi is very much less severe and more superficial in character than 
that of the pharynx, tonsils, and upper air pa 

The buccal cavity is seldom covered by the membrane, and then only 
in the worst cases of pharyngeal disease; it may line the eh. 1 r the 

lips, gums, and more or less of the hard palate, hut rarely th< It 



960 



THE SPECIFIC INFECTIOUS DISEASES. 



usually occurs in patches rather than as a continuous membrane. In a 
recent case I saw the membrane on the lower lip, extending on to the face, 
though the buccal cavity was free. Only once have I seen the membrane 
in diphtheria extend from the pharynx into the oesophagus ; it is surpris- 
ingly infrequent. The membrane is very rarely found in the stomach, and 
in no case, so far as I am aware, has the diagnosis of true diphtheria been 
confirmed by cultures. I have in several instances seen membrane in the 
stomach, cultures, however, showed streptococci, but no diphtheria bacilli. 

The middle ear is not very often involved. Otitis usually results from 
direct extension of the membrane from the rhino-pharynx through the 
Eustachian tube. It may lead to very extensive destruction of the mucous 
membrane of the tympanum, and often to permanent injury. Infection 
of the conjunctivae is also rare, and is probably due to accidental inocula- 
tion rather than to extension from the nose through the lachrymal duct. 

Diphtheria may attack an abraded cutaneous surface usually by direct 
inoculation, or it may involve a fresh wound. This is most frequently 
seen in the wound in the neck from tracheotomy. Most of the recorded 
cases in which diphtheria is stated to have involved the folds of the anus, 
the female genitals, the prepuce, or recent wounds, were observed before 
we had the means of separating by cultures, true from pseudo-diphtheria. 
A very considerable proportion of these cases doubtless belong to the lat- 
ter group. 

Visceral lesions. — The visceral lesions of diphtheria are due partly to 
the action of the diphtheria toxines and partly to the invasion of the 
body with other organisms, especially the streptococcus. It is to experi- 
mental diphtheria that we owe our most accurate knowledge of the former 
changes, for in human diphtheria the large proportion of all the fatal 
cases show evidences of so-called " mixed infection." Thus, of forty-two 
autopsies upon cases in which the diphtheria bacillus was demonstrated 
during life, Reiche * reports that both the streptococcus and the staphy- 
lococcus were found by culture in the kidney or spleen in 64%3 per cent, 
and in 45-2 per cent the streptococcus alone. He found the streptococcus 
in the kidney in some cases dying very early,— in one on the second day 
of the disease. 

The visceral lesions of diphtheria consist in wide-spread areas of cell 
death similar to those which have already been described as occurring in 
the epithelial cells of affected mucous membranes, together with hemor- 
rhages due to changes in the blood-vessels and possibly in the blood itself. 
The lesions are found in the lymph nodes, spleen, heart muscle, epithe- 
lium of the kidney, liver cells, peripheral nerves, and in the lungs. 

The lymph nodes of the cervical region are the most constantly and 



' Centralblatt fur innere Medicin, 1895, No. 3. Quoted by Welch, Transactions of 
the Association of American Physicians, 1895. 



DIPHTHERIA. 961 

the most seriously affected. Similar but less marked changes are seen in 
the tracheo-bronchial and the mesenteric groups, and in the lymph nodules 
of the mucous membrane of the stemach and intestine. There are degen- 
erative changes in the cells of the nodes most affected, with marked infil- 
tration with leucocytes and frequently small haemorrhages. The cellular 
tissue in the neighbourhood of the cervical nodes is often extensively infil- 
trated with cells. The process in the lymph nodes usually terminates in 
resolution, rarely in suppuration. 

The changes in the spleen are quite constant. The organ is swollen, 
sometimes very much so, and deeply congested. Haemorrhages are often 
seen beneath the capsule ; the spleen pulp is soft, the follicles are large, 
and cell degeneration is quite constantly observed similar to that which 
takes place in the lymph nodes. 

There are frequently small haemorrhages beneath the capsule of the 
liver, and sometimes these are seen throughout the organ. There are 
found scattered through the liver, areas of necrotic hepatic cells which are 
peculiar to this disease ; some of these areas are infiltrated with leucocytes. 

The kidneys are involved in almost all fatal cases except where death 
occurs early from laryngeal stenosis, also in nearly every severe case which 
terminates in recovery. There is in the milder cases only acute degenera- 
tion of the epithelium of the tubes and the tufts, which is the result of 
the action of the diphtheria toxines ; or in the more severe forms there 
may be acute exudative or even acute diffuse nephritis, the latter usually 
coming on at a later period of the disease. In the production of these 
two forms of inflammation, infection with streptococci probably plays the 
principal part. Welch states that hyaline changes in the glomerular 
capillaries and small arteries are characteristic features of the nephritis of 
diphtheria. 

In cases dying suddenly in the early stage of the disease, cardiac 
thrombi are occasionally found. These may be formed rapidly only a 
short time before death, or slowly during several days when the circula- 
tion is very feeble. Portions of these thrombi may be carried into the 
pulmonary or systemic circulation, causing embolism in any of the arteries 
of the extremities, the lungs, or other viscera. Even in the early fatal 
cases the heart muscle may be seriously affected ; in the later ones this is 
almost constant. The changes consist in a toxic myocarditis, the left 
ventricle being most involved. 

Degeneration of the arteries, especially of the endothelial layer, is 
occasionally seen, and there may be infiltration of the adventitia. The 
arteries of any of the viscera may be the seat of hyaline degeneration. 

The lesions of the brain are very slight and inconstant. In the spinal 

cord there have been found multiple haemorrhages into the membranes, 

and certain degenerative changes in the ganglion cells in the anterior 

horns, to which great significance was formerly attached, as they were 

71 



962 THE SPECIFIC INFECTIOUS DISEASES. 

thought to be the explanation of post-diphtheritic paralysis. These 
changes are, however, slight in comparison with those which have been 
found in the spinal nerves, with which they are generally associated. 
That diphtheritic paralysis is due not to the central lesion but to peripheral 
neuritis was first shown by Westphal in 1876, and more fully by Dejenie 
during the following year. Degenerative changes have been demonstrated 
not only in the spinal nerves but also in the hypoglossal, spinal accessory, 
motor-oculi, pneumogastric, and even in the nerves of the heart. Accord- 
ing to Sidney Martin* these nerve degenerations constitute the most 
characteristic lesion of diphtheria. (See chapter on Multiple Neuritis, 
page 785.) 

In infants and young children broncho-pneumonia is found at autopsy, 
it is safe to say, in at least three fourths of the cases, and in a large pro- 
portion of these it is the cause of death. It is well-nigh constant in cases 
of diphtheritic bronchitis of the finer tubes, and is usually present where 
the membrane has extended to the bifurcation of the trachea. The most 
important factor in the production of pneumonia is the aspiration of bac- 
teria, chiefly streptococci, from the upper air passages. These germs are 
always present in the throat, and find in diphtheria conditions most favour- 
able to their development. The pneumonia of diphtheria seems therefore 
to be due to auto-infection rather than to outside causes. Prudden and 
Northrup found streptococci almost constantly present in the pneu- 
monia of diphtheria, often in pure culture. In cases studied by others 
the streptococcus has been found alone or associated with the pneumo- 
coccus or with the diphtheria bacillus, or with both of them. 

Where there has been laryngeal stenosis, some emphysema is invariably 
present, and usually it is of the vesicular variety. In extreme or pro- 
tracted cases of stenosis there may be interstitial emphysema. Rupture 
of some of these blebs may lead to the escape of air into the cellular tissue 
of the mediastinum or of the neck, which may result in the production of 
a general emphysema of the subcutaneous cellular tissue. 

Blood.— According to the recent studies of Ewing, Morse, Billings, and 
others, there is found in all severe cases of diphtheria a reduction in the 
number of red cells to the extent of 500,000 to 2,000,000 (5,000,000 being 
assumed to be normal). There is a nearly proportionate reduction in the 
hemoglobin, this amounting to from twelve to twenty-eight per cent. 
While the haemoglobin falls coincidently with the number of red cells, 
it is regained much more slowly. Leucocytosis was found in twenty-six 
of thirty cases studied by Morse, and in forty-nine of fifty-three by Ewing. 
It is said to be generally proportionate to the severity of the attack, but is 
occasionally wanting in the most severe as well as in some of the very 
mildest cases. The increase in the leucocytes is in the polynuclear forms. 



* British Medical Journal, August 24, 1895. 



DIPHTHERIA. 963 

Symptoms. — The clinical picture of diphtheria is one which presents 
wide variations, depending upon the principal location of the disease, its 
severity, and its complications. For practical purposes the following 
seems the simplest grouping that can be made : 

1. The mild cases, in which there is either no membrane, or the 
amount of membrane is small and limited to the tonsils or to the nose, 
with few or none of the constitutional symptoms which follow absorption 
of the diphtheria poison. These cases partake essentially of the character 
of a local disease. 

2. The severe cases, which are of two kinds : first, those in which 
there are marked evidences of constitutional poisoning from diphtheria 
toxines ; and, secondly, those with laryngeal stenosis. The first form 
is usually accompanied by an extensive formation of membrane in the 
pharynx and sometimes in the nose. The larynx may be involved 
secondarily to disease in the pharynx or nose, or it may be primarily 
affected. 

3. The cases of mixed infection or the septic cases. In very many of 
the cases of the two preceding groups streptococci are found in the throat, 
but they are not in sufficient numbers or of sufficient virulence to modify 
the course of the disease. In the cases to which the term mixed infection 
is applied, in addition to the constitutional symptoms of diphtheritic 
toxasmia and the local conditions which usually attend it, there are marked 
evidences of a general septicaemia, usually due to the streptococcus. In 
these cases the symptoms of inflammation are especially prominent, not 
only in the pharynx but sometimes in the lymph glands and cellular tissue . 
of the neck, which may be followed by suppuration or sloughing. This 
form is frequently complicated by broncho-pneumonia even without laryn- 
geal disease, and sometimes by severe nephritis. 

Cases ivithout membrane. — During an epidemic of diphtheria in a 
family or an institution, cases are frequently seen which present the clin- 
ical evidences of only a catarrhal inflammation of the nose or pharynx, 
and yet cultures show the presence of the diphtheria bacillus. These 
bacilli have been found by Koplik, Park, and others to be virulent in very 
many of the cases tested, but not in all. Such cases are susceptible of two 
explanations : first, that they are examples of simple catarrhal inflamma- 
tion due to other causes, such as cocci, the diphtheria bacillus although 
present not being the active cause of the inflammation, — in other words, 
they are cases of simple catarrhal inflammation with the accidental pres- 
ence of the diphtheria bacillus; the second is, that they are cases of 
"catarrhal diphtheria," or an inflammation caused by infection with the 
diphtheria bacillus, but not of sufficient intensity to lead to the produc- 
tion of a membrane. The latter is the view of pathologists, and the one 
to which clinicians must, it seems, inevitably come. However, a mem- 
brane has so long been regarded as a sine qua non of this disease that the 



964 THE SPECIFIC INFECTIOUS DISEASES. 

existence of diphtheria without it, is something which the clinician finds 
it hard to grasp. 

Oases of the kind mentioned may be either pharyngeal or nasal. In 
the pharyngeal cases there are present the usual appearances belonging to 
a catarrhal inflammation of moderate severity, often accompanied by swell- 
ing and tenderness of the cervical lymph glands. In the cases classed as 
nasal the usual seat of the pathological process in children is the rhino- 
pharynx. There is a persistent and usually abundant nasal discharge, 
which is thin, irritating, and occasionally streaked with blood, and 
which may continue for weeks. In most of these cases constitutional 
symptoms are absent ; in a few there may be a very slight rise of tem- 
perature. The clinical evidence that these are cases of diphtheria is, first, 
that they may infect others ; and, secondly, that they may be followed by 
the sudden development of the symptoms of laryngeal diphtheria. How- 
ever, nothing but a bacteriological examination is conclusive. The mild- 
ness of these cases may be due to the fact that the bacilli are only slightly 
virulent, that their number is small, or that the resistance of the patient 
is great. Catarrhal diphtheria is not in itself serious, but it may be fol- 
lowed, particularly in young children, by laryngeal diphtheria and steno- 
sis, or, after it has existed for a time, pharyngeal diphtheria may develop 
in its usual form. Cases like those just described are to be distinguished 
from others in which bacilli, either of the virulent or the non -virulent 
variety, are found without any evidence of inflammation. 

Cases with a small amount of membrane. — Tonsillar diphtheria. — The 
exudation is usually limited to the tonsils (Plate XVII A), and may par- 
take of the character of either follicular or croupous tonsillitis ; some- 
times there is a slight extension to the faucial pillars or to the pharynx. 
These cases are quite common, and in some epidemics most of those seen 
are of this variety. They are more frequent in older children and adults 
than in infants and young children. 

The onset is accompanied by a little soreness of the throat ; the initial 
temperature is from 100° to 103° F. ; but the symptoms are often not 
severe enough to keep the patient in bed. If seen early, the throat shows 
slight redness, followed by a gray film, and later by a gray or white de- 
posit upon the tonsils. It may start as a small patch which enlarges, or 
as small, isolated spots which coalesce or remain separate. Until it disap- 
pears the membrane generally remains of its original colour. It is gener- 
ally quite adherent, and can not easily be removed with a swab ; usually it 
is sharply defined, but with a somewhat irregular outline. In many cases 
the patch is not larger than the finger nail. The inflammatory changes 
in the pharynx are slight ; a faint red areola is frequently present at the 
border of the patch. The lymph glands behind the jaw are slightly 
swollen or may be normal. There is no nasal discharge and very little 
increase in the saliva or mucus from the pharynx. The constitutional 



DIPHTHERIA. 965 

symptoms are slight, sometimes almost absent. The temperature com- 
monly continues above the normal while the membrane lasts, its usual 
range being from 100° to 102° F. The membrane remains from three to 
ten days, — a shorter time if antitoxine is used. It is very often a matter of 
surprise that so small an exudate is so persistent. The urine is generally 
normal. The parents are loath to believe that strict quarantine is neces- 
sary in so mild an illness ; and where the membrane is only upon the 
tonsils, even after the disease has run its course, the physician may be led 
to doubt the diagnosis of diphtheria. 

The points which characterize this form of the disease are : the preva- 
lence of diphtheria in the house or in the neighbourhood, a lower tem- 
perature than is usual in simple tonsillitis, the absence of marked inflam- 
matory signs in the throat, the adherence of the membrane, its duration, 
and its white, fibrinous appearance. In most cases one with experience 
can usually make an accurate diagnosis from the clinical symptoms ; but 
there are others in which the diagnosis from ordinary tonsillitis is impos- 
sible, even by the most practised observers, except by bacteriological 
examination. When diphtheria bacilli are found in these mild cases the 
question often arises whether they may not be the non- virulent form. 
Park tested forty such cases, and found the bacilli to be virulent in thirty- 
five and non-virulent in five. In twenty of the forty cases the clinical 
diagnosis was follicular tonsillitis.* 

These experiments of Park, corroborated by many other observers, 
show how great is the error of regarding lightly the possibility of infec- 
tion from mild cases. 

Unless the larynx is involved — a not very infrequent occurrence in 
young children — cases in which the amount of membrane is small almost 
invariably recover. Occasionally even such mild diphtheria is followed by 
post-diphtheritic paralysis, but usually affecting the throat only. 

Severe cases. — The onset may be gradual, even insidious. There is 
then a slight indisposition for a day or two, and perhaps some soreness 
of the throat; the temperature, however, is but little elevated, often less 
than 100° F. The symptoms may steadily increase in intensity for four 
or five days, until the maximum is reached. At other times the disease 
begins abruptly with vomiting, headache, chilly sensations, and a tem- 
perature of 103° or 104° F. Occasionally, the first thing to attract atten- 
tion is the swelling of the cervical lymph glands, which may be so great 
that mumps is suspected. The abrupt onset is more often seen in young 
children than in those who are older. 

* From one of these mild cases was obtained a bacillus whose virulence so greatly ex- 
ceeded that obtained from any other case of diphtheria, that its cultures were used for the 
preparation of toxines for injecting horses. It was by means of these powerful toxines 
that the strongest antitoxine was produced. The toxines from this bacillus are now used 
in half a dozen of the principal laboratories of this country where antitoxine is prepared. 



THE SPECIFIC INFECTIOUS DISEASES. 

The membrane upon the tonsils resembles that of the mild form pre- 
viously described, but, instead of remaining limited to them, it gradually 
spreads to the fauces, the lateral wall of the pharynx, the uvula, the 
rhino-pharynx, and into the posterior nares. The rapidity with which the 
membrane extends is in direct proportion to the severity of the attack. 
In some it may cover all the parts mentioned in twenty-four hours from 
its first appearance ; in others this may require four or five days. "When 
the nose is first affected there is an abundant discharge of serum and 
mucus, occasionally tinged with blood, which may continue several days 
before any membrane is visible. Such cases sometimes develop much more 
slowly, and no membrane may be seen in the anterior nares for a week. 

When a severe case is fully developed there is a very abundant dis- 
charge of mucus from the mouth and nose. The tonsils, the entire fau- 
cial ring, and the pharynx are covered with membrane (Plate XVII, B) 
which is at first gray and gradually becomes darker often being of a dirty 
olive-green colour. Membrane is sometimes seen upon the lips, or in 
patches in the mouth. There is obstruction to nasal respiration from the 
swelling of the palate, tonsils, and the tissues of the rhino-pharynx ; the 
mouth is half open, the breathing noisy, the tongue dry, and the lips are 
fissured and bleed readily. Occasionally large nasal haemorrhages occur 
which may necessitate plugging the nares. Both nostrils are generally 
blocked by the swelling and the false membrane ; the discharge excoriates 
the upper lip, and frequently has a fetid odour. During the second week 
there is often regurgitation of fluids through the nose, owing to paralysis 
of the palate. The lymph glands at the angle of the jaw swell rapidly; 
in severe cases they are very prominent, and there may also be extensive 
infiltration of the cellular tissue about them, although this is more char- 
acteristic of the cases of mixed infection. The local symptoms are the 
cause of much discomfort, especially the copious discharge of mucus and 
the nasal obstruction. 

The constitutional symptoms usually increase steadily with the exten- 
sion of the membrane. In the most severe cases the system is overwhelmed 
with the poison, and all the evidences of intense toxaemia are present by 
the second or third day of the disease. This is shown by great muscular 
weakness and prostration, by a feeble, rapid pulse, and a mental state of 
complete apathy or stupor, sometimes alternating with great restlessness. 
It is more frequent for the constitutional symptoms to develop gradually, 
and not to reach their height before the fifth or sixth day. The pulse 
becomes rapid, weak, and compressible, sometimes irregular ; and there is 
a great and steadily increasing anaemia. The course of the temperature is 
irregular, and bears no constant relation to the severity of the other symp- 
toms. Its usual range is from 101° to 103°, but in some of the worst 
cases it may never go above 101° F. It fluctuates irregularly with the 
development of complications, and sometimes without apparent cause. 



PLATE XVII. 





The Diphtheritic Membrane. 

A. Typical tonsillar diphtheria. 

B. Severe pharyngeal diphtheria (fatal case). 

C. Pseudo-diphtheria. The specimen is seen from behind, the larynx and trachea 
having been laid open, and shows an extensive membrane involving the epiglottis and 
the entire lower pharynx, but extending into the larynx only a short distance. It is 
also seen upon the posterior surface of the uvula and soft palate, the tonsils being only 
partially covered. The colour of the membrane is not characteristic of pseudo-diph- 
theria, as the same appearance is often seen in true diphtheria, particularly of the 
septic type. 



DIPHTHERIA. 967 

By the second or third day the urine regularly shows the presence of 
albumin, and by the end of the first week the quantity is often large. 
Granular and hyaline casts, and occasionally blood in small quantities, 
are also found. The amount of urine secreted is not noticeably dimin- 
ished, and dropsy is rare. There is complete anorexia, and often vomit- 
ing and diarrhoea are present ; in some of the cases they are prominent. 
Nervous symptoms are seen in all the very severe cases. There may be 
dulness and complete indifference to surroundings, but more frequently, 
owing to the discomfort arising from local symptoms, there is extreme 
restlessness and excitement, sometimes followed by delirium. 

At any time during the first week, but not often after that time, symp- 
toms may arise indicating that the disease has extended to the larynx. 
The first signs of laryngeal invasion usually appear from the second to the 
fifth day of the disease. There are at first hoarseness, a stridulous cough, 
and slight dyspnoea. In the severe cases these symptoms steadily increase 
until all the signs of laryngeal stenosis are present. The symptoms of 
diphtheria of the larynx, whether it begins there or follows disease of the 
pharynx, have already been described in the chapter on Diseases of the 
Larynx (page 446). The severe symptoms are due to membrane in the 
larynx ; the milder ones may arise from catarrhal laryngitis. 

The local process in the pharynx seems to be a self -limited one. By 
the fifth or sixth day it has usually reached its height, and after that the 
appearances do not change essentially for two or three days. From the 
seventh to the tenth day, in favourable cases, the diphtheritic membrane 
begins to loosen and separate from its attachment. It hangs loosely from 
the palate or uvula, and can often be pulled away in large masses. The 
detachment is frequently rapid, and in two or three days from the time 
when the first improvement is seen, the tonsils and pharynx may be almost 
free from membrane. The mucous surface left behind is of a bright-red 
colour and bleeds easily. The separation of the membrane in the nose 
and rhino-pharynx takes place more slowly. From the former it may dis- 
integrate gradually or come away en masse. With the disappearance of 
the membrane the local symptoms abate rapidly, — the discharge ceases, 
the swelling of the lymph glands subsides, deglutition becomes easy and 
natural, and nasal breathing is re-established. Simultaneously with 
these changes in the throat the constitutional symptoms improve, but 
much more slowly. Convalescence is often protracted. The anaemia and 
muscular weakness, and, most of all, the feeble heart action, may persist 
for weeks. The more severe the local disease has been, the slower is 
recovery. 

Instead of the usual course just described, the diphtheritic membrane 
may persist for two or even three weeks. In rare cases relapses occur, the 
membrane forming again after it has entirely or partially disappeared. 

The early course of the disease in the fatal cases often does not differ 






968 TEE SPECIFIC INFECTIOUS DISEASES. 

from that of the severe cases which end in recovery except in the malig- 
nant form, which kills in twenty-four or forty-eight hours, and which, 
after all, is rare. Death most frequently occurs at the height of the local 
process in the throat, usually from the fifth to the tenth day. It may be 
due to progressive asthenia the result of diphtheritic toxaemia, such cases 
being characterized by steadily increasing prostration, great anaemia, feeble, 
irregular pulse, vomiting, refusal to take food or stimulants, and mental 
apathy or stupor. Death is frequently due to heart failure, which may 
be quite sudden and occur early or late. In other cases death is due to 
complications, particularly broncho-pneumonia, rarely to nephritis or haem- 
orrhages, and in still others to invasion of the larynx. 

Even after the throat has cleared off completely the disease may end 
fatally from the occurrence of late pneumonia or nephritis or from sudden 
heart paralysis. Cases of the variety last mentioned are particularly dis- 
tressing ones, and not infrequent. It often happens that the patient is re- 
garded as convalescent, and the great vigilance of the previous days or 
weeks has been relaxed. The physician has ceased his frequent visits and 
looks in only once a day to satisfy himself that the patient is doing well, 
and all congratulate themselves that the danger is over. If the pulse is 
carefully watched, it is one day discovered that it is weaker than formerly, 
and occasionally there is slight irregularity. It is usually slower, but may 
be more rapid than normal. On inquiry, it is found that the patient does 
not take his food so well, that he has refused stimulants, and perhaps has 
vomited once or twice. Slight dyspnoea is noticed, and the face is paler 
than usual. Sometimes, within twenty-four hours from the beginning of 
such symptoms, the patient is dead. The changes for the worse occur 
very rapidly. The pulse becomes weaker, more irregular, often abnormally 
slow, but very rapid on slight exertion, and there may be a sense of prae- 
cordial weakness or distress. There are dyspnoea without cyanosis, anx- 
iety, and great restlessness, but the mind is clear. There is vomiting if 
food or stimulants are taken. The extremities are cold. Auscultation 
shows feeble and indistinct heart sounds, but no murmur. The pallor is 
extreme. Death results from sudden syncope, sometimes during an at- 
tempt to administer food, sometimes from such slight exertion as turning 
in the crib. 

Instead of such a rapid course, the same symptoms may develop more 
gradually during three or four days, the significance of the earlier symp- 
toms not being appreciated. Sometimes no premonitory symptoms are 
present, and the child falls dead after walking across the room, or sud- 
denly sitting up in bed, or after some other muscular effort, or possibly 
as a consequence of passion or excitement. 

Although such symptoms are more often seen after severe cases, they 
may occur after those of only moderate intensity, and even when the 
patient has been considered well enough to be up and about or out of 



DIPHTHERIA. 969 

doors. One little girl was considered well enough to go coasting, and died 
suddenly after the exertion. 

The explanation of sudden heart failure during or after diphtheria is 
not always the same. When it occurs at the height of the disease it is 
sometimes due to cardiac thrombosis, probably always associated with 
changes in the muscular walls. When it occurs late and follows some 
sudden muscular effort or excitement without premonitory symptoms of 
any sort, it is probably the result of changes in the muscular walls — a 
toxic myocarditis. When prodromal symptoms are present, and particu- 
larly when it is accompanied by vomiting, abdominal pain, and disturbed 
respiration, it is probably the result of a toxic neuritis affecting either the 
pneumogastric or the cardiac nerves, and is to be regarded as a form of 
post-diphtheritic paralysis. In many cases, no doubt, changes are present 
both in the nerves and in the myocardium. The other forms of diph- 
theritic paralysis which may result fatally, are discussed in the chapter on 
Diseases of the Peripheral Nerves. 

Cases of mixed infection or septic diphtheria. — The symptoms are 
usually severe from the outset. The exudation in these cases is generally 
of a yellow or dirty-gray or olive colour, sometimes being almost black 
from the presence of blood. The membrane is usually extensive, cover- 
ing the entire pharynx, often extending to the nose and the middle ear, 
and occasionally spreading to the buccal cavity. There is great swelling 
of the tonsils and uvula, and it is often impossible to obtain a view of 
the pharynx ; all the evidences of inflammation are usually more marked 
than in the severe uncomplicated cases. Sometimes the inflammation is 
of a necrotic character, and there may be extensive sloughing of the 
tonsils, the uvula, or the soft palate. The nasal discharge is generally 
abundant, and often very offensive. There is marked swelling of the 
cervical lymph glands, and frequently extensive infiltration of the cellular 
tissue of the neck, so that the head is thrown back to relieve the pressure 
upon the larynx and trachea. The swelling sometimes forms a distinct 
collar, reaching from ear to ear and filling out the whole space beneath 
the jaw. The pressure upon the jugular veins leads to congestion and 
swelling of the face and congestion of the brain. 

The general symptoms are those of a severe septicaemia. The tern- 
perature is usually higher than in simple diphtheria ; it follows no regular 
course, but is generally high and widely fluctuating, ranging from 101° to 
106° P. Dr. Biggs informs me that in the Willard Parker Hospital, in 
the cases characterized by such high temperatures, where bacteriological 
examinations have been made post mortem, there have been uniformly 
found either a general streptococcus or pneumococcus infection, usually 
the former. The pulse is weak, rapid, and compressible. The peripheral 
circulation is poor, the extremities are often cold, there is extreme mus- 
cular prostration, and both vomiting and diarrhoea are frequent. There 



970 THE SPECIFIC INFECTIOUS DISEASES. 

may be excitement, restlessness, and active delirium, or dulness, apathy, 
and stupor. Nephritis is very frequent and is often severe ; the urine 
contains a large amount of albumin and casts of all varieties, but rarely 
blood. Dropsy is not usually present, and suppression of urine is seldom 
seen. In a large proportion of the children under three years old broncho- 
pneumonia develops. This is indicated by the accelerated breathing, 
higher temperature, and cough, and often occurs even when the larynx 
is not involved. The spleen is usually enlarged, and frequently the liver 
also. Such severe symptoms continue for from two days to a week ; the 
patient may die from the sudden invasion of the larynx, or there may be 
suppression of urine and uraemic convulsions ; but more frequently the 
cause of death is astheuia or broncho-pneumonia. Death usually occurs 
while the local disease is at its height. Occasionally it comes later from 
heart failure, where the signs of local improvement may have begun. 

Eecovery from this type of the disease is rare, and those who manage 
to escape the dangers of the acute period have still others to encounter. 
Among the latter may be mentioned : extensive sloughing in the throat or 
of the cellular tissue of the neck, which may be followed by severe or 
even fatal haemorrhage, diffuse suppuration of the same region, nephritis, 
which may develop as late as the end of the second or even the third 
week and may prove rapidly fatal, late pneumonia or pleurisy, and finally 
paralysis of the heart or respiration, as in the severe uncomplicated cases. 

Complications and Sequelae. — Most of the complications of diphtheria 
have already been mentioned either under the head of Lesions or Symp- 
toms. It only remains to consider their clinical association. 

Otitis is not very frequent. It occurs particularly in the rhino- 
pharyngeal cases, and is sometimes due to the diphtheria bacillus alone, 
but more often to mixed infection. The type of inflammation is usually 
a severe one, and it may be accompanied by necrotic changes in the drum 
membrane which resemble those of scarlet fever. 

Broncho-pneumonia is the most frequent complication in young chil- 
dren. It occurs especially in laryngeal cases, and in those of a septic 
type whether the larynx is involved or not. Pneumonia usually develops 
at the height of the disease, although it is occasionally seen late and even 
during convalescence. Other pulmonary complications are infrequent. 
Pleurisy with a serous effusion may occur in connection with severe 
nephritis, and empyema in septic cases. Emphysema is a complication of 
laryngeal diphtheria ; it is nearly always vesicular, sometimes interstitial, 
and may become general, extending into the cellular tissue of the neck 
and afterward that of the entire body. Pericarditis, endocarditis, and 
meningitis are all very rare and are seen chiefly in septic cases of the most 
severe type. Myocarditis is much more frequent, and is present to a 
greater or less degree in nearly all severe cases, although in but a small 
proportion of these does it give rise to distinct symptoms. It is closely 



DIPHTHERIA. 971 

connected pathologically with degeneration of the cardiac nerves, and it 
may be a cause of sudden death at any time during the acute period of 
the disease or during convalescence. 

Thrombosis and embolism are among the less frequent complications. If 
cerebral, they may cause hemiplegia, aphasia, and sometimes convulsions ; if 
peripheral, they usually affect one of the lower extremities, where they may 
cause sudden pain, numbness, and coldness of the limb, followed by partial 
paralysis, oedema, and sometimes even by gangrene. Thrombosis of the pul- 
monary artery or of the heart may be a cause of sudden death, the symptoms 
being dyspnoea and precordial distress, with pallor or cyanosis. Both throm- 
bosis and embolism are associated with a very feeble action of the heart, and 
generally they are preceded by degenerative changes in its muscular walls. 

Haemorrhages are usually nasal, and while in most cases they are not 
serious, they may necessitate plugging of the posterior nares. Bleeding 
from any other mucous membrane may occur, but it is rare except from 
the mouth. Subcutaneous haemorrhages are not very infrequent, and are 
evidence of a very high degree of diphtheritic toxaemia. They usually oc- 
cur as small petechial spots, but are sometimes extensive. They may be 
seen upon almost any part of the body, most frequently upon the abdomen 
and lower extremities ; but the most extensive extravasation I have ever 
seen was in the neck, reaching from the clavicle almost to the ear and 
covering nearly one lateral half of the neck. 

Albumin is present in the urine of almost every case of moderate 
severity, usually depending upon acute degeneration of the kidney. Severe 
nephritis is most frequently seen in septic cases. It usually develops at 
the height of the local disease, but may come during convalescence. The 
most common form is acute exudative nephritis, in which there are albu- 
min and casts in the urine, but rarely dropsy or signs of uraemia. It is 
seen in most of the fatal septic cases except those due to laryngeal ob- 
struction, but it is seldom a cause of death. Less frequently acute diffuse 
nephritis occurs, with dropsy, scanty urine or even suppression, vomitiug, 
and all the usual symptoms of acute uraemia. It may be a cause of death. 

Functional disturbances of the stomach are very frequent, and are in 
fact present in most of the severe cases, but lesions of the mucous mem- 
brane are rare. While diarrhoea is often seen without intestinal lesions, 
the latter are of frequent occurrence. The most characteristic form of 
inflammation is a follicular entero-colitis, which seldom goes on to ulcera- 
tion. It is extremely rare that the membranous form is seen, and then 
it is generally associated with the presence of streptococci, not diphtheria 
bacilli. The intestinal symptoms usually begin while the process in the 
throat is at its height, but often continue for some time after the throat 
has cleared. Although severe intestinal inflammation is rare, it is a most 
serious complication when it occurs, which is generally in infants and very 
young children. 



972 THE SPECIFIC INFECTIOUS DISEASES. 

Diphtheria is usually followed by a severe and often persistent anaemia 
which may continue for weeks. Pneumonia, nephritis, and cardiac disease 
may first show themselves during convalescence, and so be ranked as 
sequelae. The most important sequel of diphtheria, however, is multiple 
neuritis or post-diphtheritic paralysis (page 790). 

Diagnosis. — The diagnosis of diphtheria rests upon two kinds of evi- 
dence — clinical and bacteriological. While the bacteriological diagnosis 
is, on the whole, more exact, it should not be depended upon to the exclu- 
sion of the clinical diagnosis. The prevailing tendency to disregard the 
clinical evidences of the disease and rely wholly upon bacteriology, is 
greatly to be deprecated. These means of diagnosis are not mutually ex- 
clusive, but complementary. Bacteriology applied to the diagnosis of 
diphtheria has rendered incalculable service, but it has its limitations. As 
has well been said by Welch, the mere presence of the diphtheria bacilli in 
the throat of a patient no more proves that he has diphtheria, than the 
presence of the pneumococcus in his saliva establishes the fact that he has 
pneumonia. Again, the case may be one of undoubted diphtheria and 
yet the bacilli may not be found at the first examination, although they 
are found at subsequent examinations — a thing which has repeatedly hap- 
pened in my own experience. The delay thus occasioned in the applica- 
tion of early treatment is a matter of the greatest importance, especially in 
connection with serum therapy. Finally, because of the occasional presence 
in the throat of a non-virulent diphtheria bacillus and of the so-called 
pseudo-diphtheria bacillus, even a positive report by the bacteriologist may 
be misleading ; but after all this will seldom be the case in actual practice. 
While in no way detracting from the immense advantage of having bac- 
teriological assistance in making the diagnosis, I insist that the clinical 
manifestations of diphtheria must be observed by the physician with the 
same care as heretofore, particularly since the great body of the profession 
are as yet compelled by circumstances to rely solely upon a clinical diag- 
nosis. Every one who has seen much of the two methods of diagnosis 
studied side by side will, 1 think, admit that in fully four fifths of the 
cases an accurate clinical diagnosis can be made after twenty-four hours' 
observation, and in a considerable proportion of these in a shorter time ; 
the remaining one fifth require either a longer period of observation or 
continue doubtful to the end. The great majority of the cases of this 
group are of the mildest variety and terminate in recovery. In them an 
accurate diagnosis is of importance more for the sake of others than for 
the patient himself. 

1. The Clinical Diagnosis. — In arriving at this, there must be con- 
sidered, first, the patient and his surroundings ; secondly, the constitutional 
or general symptoms ; thirdly, the local evidences of disease. The chances 
of diphtheria are greatly increased if the patient is a child under ten years 
of age, if his home is in a tenement house or an institution, if he attends 



DIPHTHERIA. 973 

a public school where he mingles with children coming from all sorts of 
homes, and if there are other cases in the family or in the neighbourhood. 
On the contrary, the chances are much lessened if the patient is over ten 
years old, if he lives in a private house, if there is no diphtheria in the 
neighbourhood, and if he does not mingle with children who come from 
doubtful or infected localities. In tonsillitis a history of repeated attacks 
is often obtained, and is of some value. If the throat symptoms occur 
with measles or scarlet fever, the time of their development is of much 
importance ; when they precede the eruption or appear while the fever is 
at its height, the disease is rarely true diphtheria ; while, if they develop 
at a later period or after defervescence, diphtheria is highly probable. 

The mode of onset and the constitutional symptoms are of some im- 
portance in diagnosis, but diphtheria develops in such a variety of ways 
that, taken by themselves, the constitutional symptoms prove little. The 
onset of diphtheria is more frequently gradual, and the initial temperature 
is more often low, than is the case with other throat inflammations ; but 
the exceptions are many. Diarrhoea, vomiting, coated tongue, and an- 
orexia, count for little on either side. The presence of a nasal discharge, 
especially if abundant, ichorous and tinged with blood, the early develop- 
ment of the symptoms of croup, the rapid enlargement of the cervical 
lymph glands, and the early appearance of albumin in the urine, — all point 
strongly to diphtheria. Later symptoms which are especially diagnostic 
are marked anaemia, progressive asthenia, intense toxaemia often with a 
low temperature, very feeble pulse which is sometimes slow, sometimes 
rapid, sudden attacks of syncope, nasal haemorrhages, nasal regurgitation 
from paralysis of the soft palate, contagion, and, finally, the development 
of post-diphtheritic paralysis of the muscles of the throat, eye, or extremi- 
ties, with paralysis of the heart or respiration. 

For early diagnosis much more reliance is to be placed upon the local 
appearances than upon the general symptoms. The characteristic mem- 
brane of diphtheria appears, in the great majority of cases, first upon the 
tonsils usually as a gray film, which gradually becomes more dense and 
white, and often has the look of being plastered on. The colour of older 
membrane is gray, greenish-yellow, brown, sometimes black. Beginning 
as a small patch, it soon spreads so as to cover the tonsils. It frequently 
affects one tonsil twenty-four or thirty-six hours before the other, and 
occasionally it is confined to one side. In exceptional cases it begins in 
the crypts of the tonsil and appears as isolated dots, which may coalesce 
to form a continuous patch like that already described, or it may remain 
isolated like the exudate of an ordinary follicular tonsillitis. When the 
membrane is removed it usually requires some force, and the entire patch 
may come away, leaving bleeding points, but it reforms in most cases 
within twenty-four hours. More important still for diagnosis is the fact 
that the membrane spreads from the original seat, and also the manner of 



974 THE SPECIFIC INFECTIOUS DISEASES. 

its spreading. If it extends from the tonsils to the faucial pillars and the 
uvula, it is almost surely diphtheria ; so also in most cases when it extends 
to the lateral walls of the pharynx. Doubtful patches on the tonsils or 
fauces followed by symptoms of croup, may be considered as diphtheria 
with almost absolute certainty. The rapidity of the spreading varies 
much in the different cases, depending upon the intensity of the infec- 
tion ; but the gradual extension beyond the tonsils, as shown by observa- 
tions made at intervals of eight or twelve hours, usually settles the diag- 
nosis in the primary cases. However, if the throat symptoms complicate 
measles or scarlet fever the above rules do not apply. Such cases are to be 
judged by the time at which the membrane appears, as already stated. 

In pure diphtheria there is a notable absence of oedema of the faucial 
pillars and uvula, so common in throat inflammations due to cocci. In 
fact, whenever there are seen in the throat evidences of a very high degree 
of inflammation, it points either to mixed infection or to false diphtheria. 
The same is true of a very friable membrane, yellow in colour from the 
presence of pus cells, and also of deep sloughing of the tonsils or the pil- 
lars of the fauces. 

Primary membranous inflammation of the larynx may always be safely 
regarded as diphtheria ; but if there is no visible membrane, the diagnosis 
is rendered positive only by a bacteriological examination. This may be 
true of many nasal cases where the only symptoms are a discharge of the 
character previously described. Such cases may continue for weeks with 
no symptoms other than the discharge. Some of them are examples of 
catarrhal diphtheria; in others, membrane is present in the post-nasal 
space or in the nose itself. 

The most characteristic clinical differences between diphtheria and 
other inflammations accompanied by an exudation upon the throat or in 
the nose — i. e., pseudo-diphtheria — are shown in the following table : 

DIPHTHERIA. PSEUDO-DIPHTHERIA. 

1. Often a history of exposure to a pre- 1. Usually none, 
vious case. 

2. Prevails epidemically. 2. It is questionable if it ever does. 

3. Onset often gradual, with low tern- 3. Onset usually abrupt, with high tem- 
perature and slight constitutional symp- perature and quite marked constitutional 
toms. symptoms. 

4. Previous attacks rare. 4. Often a history of repeated attacks. 

5. Often begins in the larynx. 5. Seldom if ever does so when primary. 

6. If pharyngeal, often shows a strong 6. This tendency is much less marked, 
tendency to extend to the larynx. 

7. Primary cases frequently severe. 7. Rarely severe unless secondary, par- 

ticularly to measles or scarlet fever. 

8. When it complicates measles or scar- 8. Usually occurs at the height of the 
let fever it often develops late, after pri- primary disease, sometimes even preceding 
mary fever has subsided. the eruption. 



DIPHTHERIA. 



975 



DIPHTHERIA. 

9. The middle ear not so often involved. 

10. Occasionally limited to the nose 
(croupous rhinitis). 

11. Adenitis constant; not much sur- 
rounding inflammation, except in cases of 
mixed infection ; suppuration is rare. 

12. Albuminuria the rule, except in the 
mildest cases. 



13. Nasal regurgitation from paralysis 
of the palate in the second week or later. 

14. Toxic symptoms common : asthe- 
nia ; great anaemia after the fourth or fifth 
day ; later, sudden heart paralysis, respira- 
tory paralysis, or post-diphtheritic paraly- 
sis of throat, eyes, or extremities. 

15. The membrane usually thicker and 
more adherent ; can often be removed in 
large masses. 

16. Greater tendency to spread from its 
original seat. 

17. Longer duration noticeable, espe- 
cially in mild cases, where it may last five 
to ten days. 

18. Usually less evidence of inflamma- 
tion of mucous membrane and in surround- 
ing parts. 

19. After removal of membrane a red 
surface left ; ulceration slight and super- 
ficial ; rarely a tendency to sloughing. 

20. A very extensive membrane of a 
white or pearl-gray colour, covering ton- 
sils, uvula, fauces, pharynx, and nose, is 
almost invariably true diphtheria, if pri- 
mary. 

21. A thick gray membrane, not re- 
movable without force, with little or no 
inflammation, and although confined to 
the tonsils lasting five or six days, is al- 
most invariably true diphtheria. 



22. A membrane on the tonsils, similar 
to that described, with isolated adherent 
patches on the uvula or anywhere in the 
pharynx, is usually diphtheria : doubtful 
patches upon the tonsils followed by croup, 
almost invariably diphtheria. 



PSEUDO-DIPHTHERIA. 

9. Much more frequently; in scarlet 
fever almost invariably. 

10. Doubtful if it ever is so. 

11. Adenitis often slight or absent in 
primary cases ; in scarlet fever, marked in- 
flammation which extends to tissues around 
the glands ; frequently suppurates. 

12. Rarely seen in primary cases, and 
sometimes not in secondary form, even 
though the symptoms are severe. 

13. Never seen. 

14. Septic symptoms frequent, but the 
peculiar toxic symptoms are never seen. 



15. Thinner, more friable, and less ad- 
herent ; rarely removed in large masses. 

16. Tendency much less ; in most pri- 
mary cases membrane limited to tonsils. 

17. Shorter duration ; three to five days. 



18. Evidence often of intense inflam- 
mation. 

19. In bad cases, often marked ulcera- 
tion with deep sloughing and suppuration. 

20. An exudation of isolated yellow 
dots which never coalesce, confined to the 
tonsils, with considerable swelling and evi- 
dence of inflammation and usually with 
a high temperature, is seldom true diph- 
theria. 

21. An exudation of soft, yellow patches, 
changing to a dirty green, which can be 
partly or entirely wiped off without hem- 
orrhage, whether confined to the tonsils 
or extending to the pillars of fauces and 
lasting only three or four days, is seldom 
true diphtheria. 

22. Cases with much general inflamma- 
tion of the tonsils and pharynx, with small 
patches of a yellow exudate, are seldom 
true diphtheria. 



976 THE SPECIFIC INFECTIOUS DISEASES. 

The difficulties of diagnosis are greatest in the mild cases and in the 
early stage. There are very few cases, except those of the mildest type, in 
which a diagnosis is not possible by the course of the disease ; but there 
are very many in which an early diagnosis is impossible without cultures. 

It is not often difficult to distinguish diphtheria from any other dis- 
ease ; but the exudation upon the pharynx or tonsils may be confounded 
with thrush or herpes. This mistake can scarcely be made by one who 
examines a case with any degree of care. The appearance of the tonsils 
on the second or third day after tonsillotomy has been performed, may 
be easily mistaken for diphtheria by one who is unfamiliar with the ap- 
pearance of the wound. 

Diphtheria of the mouth may be mistaken for herpetic or ulcerative 
stomatitis. It is, however, much more common for these latter affections 
to be called diphtheria than for the opposite mistake to be made. Diph- 
theria of the mouth alone is so rare that it may almost be dropped from 
consideration. As a rule, this is seen only in the worst cases of pharyn- 
geal diphtheria. 

It is sometimes difficult to distinguish cases of scarlet fever in which 
the throat symptoms are severe and appear early, from cases of primary 
diphtheria. In many of these cases the eruption appears late, and is not 
characteristic. Much importance is to be attached, as pointing toward 
scarlet fever, to a prevailing epidemic, a history of exposure, a sudden 
onset with severe symptoms, vomiting, prostration, very high temperature, 
and to a very active inflammation in the pharynx. In all cases with a 
sudden onset, in which from the throat symptoms one is inclined to make 
a diagnosis of diphtheria, the possibility of scarlet fever should not be 
forgotten ; and one should never omit to examine the patient thoroughly 
for an eruption. The diagnosis of primary diphtheria of the larynx has 
already been considered (page 447). 

2. The Bacteriological Diagnosis.* — The technique. — In many cases an 
immediate diagnosis may be reached by smearing a cover-glass with a 
swab which has been drawn over the diphtheritic membrane; the cover- 
glass is then dried and stained. Although in the hands of an expert this 
method is fairly exact, it is not adapted to general use, as bacilli directly 
from the throat are much less typical than those from cultures, and the 
chances of contamination are much increased. Furthermore, the mouth 
often contains bacilli which somewhat resemble the Loeffler bacillus ; so 
that on the whole the result is more likely to be doubtful than if cultures 
are made. 



* I am greatly indebted for many facts in these pages to the Scientific Bulletin 
No. 1, of the New York Health Department, in whose bacteriological laboratory, under 
the supervision of Drs. H. M. Biggs and W. H. Park, some of the best work in the 
world in the bacteriological diagnosis of diphtheria has been done. 



PLATE XVIII. 









W si 


* 


m r 


»» 


| 


u 






' 










>>.' 



4 



I v . t , 











Diphtheria Bacilli and their Associates. 

1 and 2, colonies of diphtheria bacilli under a low and a high power ; 3, 4, 5. char- 
acteristic diphtheria bacilli x 1,000; 5, showing the short even-stained diphtheria 
bacilli: 6, pseudo-diphtheria bacilli; 7. streptococci from a serum culture; 8, strep- 
tococci from a smear directly from the throat. (After Park.) 



DIPHTHERIA. 977 

In making cultures there is required a sterilized swab and a tube or 
plate of Loeffler's blood-serum (page 952). The swab is made from a 
piece of wire roughened at one end where it is wound with absorbent 
cotton. In taking a culture from the throat, the tongue should be de- 
pressed and the tonsils, pharynx, or other seat of visible membrane rubbed 
firmly with the swab, which is then wiped over the surface of the culture- 
medium in the tube or on the plate. In laryngeal cases the culture should 
be taken from the posterior wall of the pharynx, and in nasal cases from 
the nostril. The tube or plate is then placed in an incubator for twelve 
or fourteen hours and kept at a temperature of about 100° F. (37° C), at 
the end of which time the colonies (Plate XVIII, 1 and 2) may be exam- 
ined. A sterilized platinum needle is dipped into a colony and washed 
off in a drop of sterilized water upon the cover-glass, dried in the air, and 
then heated by passing several times over an alcohol flame and stained for 
ten minutes with Loeffler's solution of alkaline methyl blue, without heat- 
ing ; after which it is rinsed, dried, and mounted in balsam. Examina- 
tion with an oil-immersion lens, in the great majority of cases, shows 
either a great number of diphtheria bacilli (Plate XVIII, 3, 4, and 5) 
and a few cocci, or only cocci in pairs or short chains (7 and 8) ; 
exceptionally, the cocci and bacilli may be present in nearly equal 
numbers. 

Although the first slide may seem conclusive, a positive opinion should 
not be given without examining at least three colonies from different 
parts of the specimen. The diagnosis is completed by testing the viru- 
lence of the bacilli found. This is usually done by injecting a guinea-pig 
with a pure broth-culture. When death occurs within seventy-two hours, 
the bacilli are said to be fully virulent. 

The reliance to be placed upon bacteriological diagnosis. — Many mis- 
leading statements have been published in regard to the relative frequency 
of cases of membranous inflammation due to the diphtheria bacillus and 
to other bacteria. My own experience coincides fully with the state- 
ments made by Welch and Baginsky, that in the great proportion, fully 
ninety-five per cent, of the cases in which one would unhesitatingly make 
the diagnosis of diphtheria by clinical symptoms, the Loeffler bacillus is 
found, provided proper precautions are observed. It will almost invari- 
ably be found: (1) if there is visible membrane in the pharynx; (2) if 
the culture is made during the period in which the membrane is form- 
ing; (3) if no antiseptics have been applied shortly before using the 
swab ; (4) if the culture has been made with sufficient care to avoid con- 
tamination. 

The diphtheria bacillus sometimes disappears early ; hence cultures 
made while the membrane is loosening may be negative. If the mem- 
brane has disappeared, or if none has been present, it may be necessary, as 
-has been shown by Koplik, to go into the tonsillar crypts with probe or 
72 



978 THE SPECIFIC INFECTIOUS DISEASES. 

spoon to discover bacilli.* It is therefore important in all cases to con- 
sider the duration of the disease before drawing a conclusion from a nega- 
tive culture. If' the case is one of laryngeal disease without pharyngeal 
exudation, a negative culture from the pharynx in the early stage is not 
uncommon, although a little later bacilli may be coughed up and found 
in the pharynx in abundance. Hence negative results are most frequent 
late in pharyngeal and early in laryngeal cases. A single negative culture 
is never to be taken as conclusive, although in most conditions other than 
those mentioned it may be so regarded. 

The next question for consideration is how far one is justified, from 
the microscopical appearances of bacilli and from their mode of growth, 
in deciding that they are virulent, without resorting to the test of animal 
inoculations. The consensus of opinion among bacteriologists at the pres- 
ent time is that, for diagnostic purposes, all bacilli present in suspicious 
throats, having the morphological and cultural characteristics of diph- 
theria bacilli are to be regarded as virulent unless the contrary is proved, 
the latter being very infrequent. This is equally true of bacilli from both 
mild and severe cases, for it is well known that the most virulent bacilli 
are often found in cases clinically of a mild type. 

Non-virulent bacilli resembling the Loeffler bacillus. — There may be 
found in throats two forms of bacilli which resemble the diphtheria bacil- 
lus and which may occasionally be a source of error. The first is the non- 
virulent diphtheria bacillus, a form which corresponds in every other 
characteristic with the Loeffler bacillus, but which lacks virulence as shown 
by animal tests. The exact status of this form is not yet fully determined. 
The view most widely accepted is that of Eoux and Yersin — viz., that they 
are simply diphtheria bacilli which have lost their virulence. The other 
form, though in many particulars resembling the Loeffler bacillus, differs 
from it in being shorter, plumper, and more uniform, in size, and in pro- 
ducing an alkali in broth cultures ; to this the term pseudo-diphtheria 
bacillus f (Plate XVIII, 6) has been given. It is more frequently seen 
than the form just described and like it is non-virulent. Both these forms 
of bacteria are rare in throats where a suspicion of diphtheria exists. 

The presence of virulent bacilli in the throats of healthy persons. — 
That virulent bacilli may be harboured for an indefinite period in the throat 

* Dr. Martha Wollstein, pathologist to the Babies' Hospital, has reported to me the 
following case illustrating this point: The first swab from a doubtful exudate upon 
the tonsil revealed the Loeffler bacillus. The case was reported to the Board of Health, 
who a day or two later took a culture from the throat, the exudate having at that time 
disappeared, and reported the case as negative. On the following day Dr. Wollstein 
made a second culture from the tonsillar crypts, finding as before the Loeffler bacilli 
in great numbers. Such cases indicate how great caution must be observed in drawing 
conclusions from negative cultures, especially if made late. 

f An unfortunate term, as this bacillus has nothing to do with the form of angina 
classed as pseudo-diphtheria, which is generally due to the streptococcus. 



DIPHTHERIA. 979 

or nose of a healthy person is proved by many observations. In Escherich's 
well-known. case, the throat of an apparently healthy nurse, under whose 
care a number of cases of diphtheria had developed, was found to contain 
numerous virulent bacilli which remained for weeks. In a case observed 
by Park, virulent bacilli were found for months in the nose of an apparently 
healthy infant, and this child communicated diphtheria, it was believed, 
to two other members of the family, without itself ever suffering from the 
disease. Similar instances have been reported by Feer, Loeffler, and 
others ; but they are to be regarded as very exceptional. However, the 
presence of bacilli in the nose or throat of a child who has been ex- 
posed to diphtheria is of very common occurrence. The New York 
Health Department made observations upon forty-eight children in four- 
teen families in which one or more cases of diphtheria had occurred, and 
where no attempt at isolation had been made. In one half these cases 
bacilli were found, and animal tests showed them to be virulent in every 
one of six cases tested, although four of the children did not develop 
diphtheria. Of the entire number, forty per cent subsequently developed 
diphtheria. My own experience in two institutions where diphtheria 
has been endemic, fully confirms the observation that bacilli of all degrees 
of virulence are very frequently found in the noses or throats of such 
exposed children, although a large proportion of them never develop 
the disease. Outside of institutions and infected tenement houses, how- 
ever, such a condition is extremely rare. In a series of three hundred 
and thirty cases studied by Park, in which no exposure to diphtheria was 
known, virulent bacilli were found in but eight persons, two of whom 
subsequently developed the disease. In twenty-four of this series, non- 
virulent diphtheria bacilli were found, and in twenty-seven the pseudo- 
diphtheria bacillus. Any person, but especially a child who has been in 
contact with a case of diphtheria, may receive bacteria into the throat, 
where they may be present for days or weeks before the disease develops, 
and such persons may convey the disease to others, although they them- 
selves may never have it. 

Summary.— I. For ordinary diagnostic purposes the discovery in the 
throat of a case of suspected diphtheria, of bacilli having the appearance of 
the Loeffler bacillus, may be regarded as conclusive evidence of diphtheria. 

2. Cultures may yield negative results late in pharyngeal cases when 
the membrane is separating or after it has disappeared, or early in laryn- 
geal cases; but in no instance is a single negative culture to be regarded 
as conclusive. 

3. Both the local appearance of the throat and the stage of the disease 
are always to be considered in connection with the bacteriological report. 

4. Virulent bacilli are frequently found in the noses or throats of 
children exposed to diphtheria, apart from all throat lesions. Such a find- 
ing is not in itself evidence that these persons have diphtheria, although, 



980 THE SPECIFIC INFECTIOUS DISEASES. 

inasmuch as they may infect others and as a considerable proportion of 
them subsequently develop diphtheria themselves, they should be re- 
garded with suspicion and if possible kept under observation. 

5. Non-virulent bacilli are occasionally, and virulent bacilli are rarely, 
found in the throats of healthy persons where there is no history of expos- 
ure to diphtheria. 

6. The existence of a membranous inflammation in the nose or phar- 
ynx, associated with the presence of diphtheria bacilli, is conclusive evi- 
dence of the existence of diphtheria. 

7. The presence of such bacilli, associated with marked evidences of 
catarrhal inflammation of the mucous membrane, is likewise evidence of 
diphtheritic infection. 

Prognosis. — There is no disease in which it is more difficult to foretell 
the outcome than in diphtheria, and none in the course of which unex- 
pected dangers more often arise. So many possibilities exist that even the 
mildest case must be regarded as serious and carefully watched, since we 
can never know when unfavourable symptoms may develop. Jacobi puts 
it well when he says, " The physician will often be deceived, and more 
frequently in mild cases than in severe ones." In perhaps the majority 
of cases it is impossible to tell how severe the attack will prove before the 
third or fourth day of the disease. 

The factors to be considered in the prognosis of any given case are : the 
age and previous condition of the patient ; the time when treatment is 
begun ; the extent of the membrane and the rapidity with which it is 
spreading ; the degree of diphtheritic toxaemia as shown by the condition 
of the pulse and the nervous symptoms; whether or not the membrane has 
invaded the larynx ; and the presence or absence of complications, espe- 
cially nephritis and broncho-pneumonia. Pure diphtheria has usually a 
better prognosis than cases of mixed infection. 

So many circumstances modify the death-rate of diphtheria that figures 
are of no value for comparison unless their source is considered. There 
must always be taken into account, the age of the patients treated and 
whether the statistics are drawn from private or hospital practice ; if the 
latter, what sort of cases are received at the hospital and the treatment 
employed. Diphtheria is very fatal during the first two years of life, 
from two causes : first, from its strong tendency to invade the larynx and 
lower air passages ; and secondly, from the frequency with which broncho- 
pneumonia occurs as a complication, both with and without membrane 
in the larynx and trachea. Of eighty-five consecutive cases under twenty- 
six months of age observed in the New York Infant Asylum, in a period 
extending over two years, the mortality was 68 per cent ; in over two 
thirds of the fatal cases the disease involved the larynx. In diphtheria 
hospitals, where most of the mild cases included in the above statistics 
would probably not have been admitted, the mortality in children under 



DIPHTHERIA. 981 

two years "has varied from 60 to 80 per cent ; in private practice it has 
ranged for this age from 30 to 60 per cent — i. e., without antitoxine. 

After the second year there is a steady fall in the mortality up to pu- 
berty. From a comparison of many statistical tables it may be stated that, 
under the same conditions, the mortality from two to five years is two 
thirds the mortality of the first two years ; while that from five to ten 
years is one half, and that from ten to fifteen years about one fifth the 
mortality of the first two years. Series of cases from different sources and 
treated by different methods show very nearly this relative mortality. 

In some seasons a mild type of the disease prevails, the number of 
laryngeal cases is small, and the mortality therefore is less than half that 
which is usually seen. In other seasons, with the opposite conditions, the 
mortality may be trebled. The influence of the method of treatment 
upon the mortality will be considered in the pages devoted to treatment. 

There has been considerable discussion as to what influence the gen- 
eral introduction of bacteriological diagnosis has had upon diphtheria 
statistics. While many cases of pseudo-diphtheria, most of which recover, 
have been excluded, there have been included many cases formerly re- 
garded as examples of simple tonsillitis. According to the data collected 
by the Xew York Health Department, there are excluded by bacteriology 
more cases than are included. In April, 1896, there were reported to the 
Department as diphtheria (without a bacteriological examination) 107 cases 
which were proven by cultures to be pseudo-diphtheria ; while during the 
same month there were 80 cases returned as doubtful or as pseudo-diph- 
theria, which by bacteriological examination were proven to be true 
diphtheria. The results obtained in several other months were very 
similar. 

It can not be too often emphasized that the danger from diphtheria is 
not over when the throat has cleared off. The most frequent cause of 
death after this time is heart paralysis, which may come very suddenly. 
This danger exists after every severe case and it occasionally occurs after 
those in which the early symptoms were only of moderate severity. Less 
frequently death late in the disease is due to paralysis of respiration, to 
nephritis, or to broncho-pneumonia. 

Prophylaxis. — In no infectious disease can so much be accomplished 
in the way of prevention as in diphtheria. 

Public funerals of children dying from diphtheria should at all times 
be prohibited. Schools should be closed whenever the disease is epidemic. 
Children from families where diphtheria exists should not be allowed to 
attend school, not only ordinary day schools, but Sunday schools, dancing 
schools, and the like; first, for the reason that they may, while healthy, 
be the carriers of the disease, but, what is even more important, that they 
may mingle with other children while themselves suffering from diphthe- 
ria in an early stage or in a mild form. Such children should be kept 






982 THE SPECIFIC INFECTIOUS DISEASES. 

from school for at least two weeks after the recovery of the last case in 
the family. 

In every large city, hospitals for diphtheria patients should be estab- 
lished, not only for the poor, but with private rooms for cases developing 
in hotels, boarding houses, or in any place where isolation is impossible. 
The removal of diphtheria patients from tenement houses to a hospital 
should be insisted upon whenever there are other children in the family. 
Every city should be provided with a steam disinfecting plant, where car- 
pets, blankets, bedding, etc., can be sent from the sick-room for disinfec- 
tion. It is also desirable that the board of health in every city have a 
bacteriological laboratory,* where the diagnosis in all doubtful cases may 
be settled by means of cultures, in order that proper and necessary means 
of prophylaxis may be taken in every case of true diphtheria, even though 
it is mild, and also that unnecessary expense and trouble be not imposed 
in cases of pseudo-diphtheria. 

Quarantine. — Not only every undoubted case of diphtheria, but every 
suspected case, should be immediately isolated. Quarantine for the latter 
should continue until the diagnosis is settled either by a bacteriological 
examination or by the course of the disease. Positive and suspected cases 
should not be isolated together. The quarantine in every instance must 
be complete ; no person should be allowed in the room except the attend- 
ants and the physician. The meals and everything else required by the 
patient should be left outside the door. 

Bacteriology has furnished some very definite data from which the 
necessary duration of the period of quarantine may be determined. In 
this the physician is to be guided by the time that the bacilli remain in 
the throat, for the patient is to be considered as dangerous while they per- 
sist. This point was investigated by the New York Health Department 
in 605 cases : In 304 of these the bacilli had disappeared by the third 
day after the membrane was gone ; and in 301 they persisted for a longer 
time, — in 176, for seven days; in 64, for twelve days; in 36, for fifteen 
days ; in 12, for twenty-one days ; in 4, for twenty-eight days ; in 4, for 
thirty-five days; and in 2, for sixty-three days. While it is unquestion- 
ably true that in a certain number of cases these persistent bacilli have 
been found non-virulent, the opposite has been frequently shown. Of 15 
cases in which the virulence was tested, virulent bacilli were found in 9 
at periods varying from eight to twenty-five days after the membrane was 
gone. Tobiesen found that of 46 patients leaving the hospital under 
ordinary rules, virulent bacilli were present in 24 at the time of their dis- 
charge. The general rule should be to contiuue quarantine until a cul- 

* The example of the New York Health Department in establishing a municipal 
laboratory for the bacteriological diagnosis of diphtheria has now been followed by 
nearly every large city in this country. 



DIPHTHERIA. 983 

ture shows the throat to be free from bacilli; in the absence of the 
culture test, quarantine should be continued in mild cases for ten days, 
and in severe cases for three weeks, after the membrane has disap- 
peared. The danger after this period in either instance is very slight ; 
for even where virulent bacilli are found long after the membrane has 
disappeared, their number is usually small. The rules above given 
should be followed with reference to children returning to school or 
mingling with -other children, and adults who are thrown into close con- 
tact with children. 

Treatment of suspected cases. — During an epidemic of diphtheria every 
sore throat should be looked upon with suspicion, and every such case iso- 
lated as soon as any exudation appears upon the tonsils, or a watery nasal 
discharge begins. In institutions it is desirable that cultures be made 
from suspicious cases of pharyngitis, even though no membrane is pres- 
ent. All such patients should be separated from the other inmates of the 
home or the institution, and while waiting for the results of the bac- 
teriological examination or for positive symptoms, antiseptic gargles should 
be used. If there are patches on the tonsils, the case should be treated as 
true diphtheria, in order that no time may be lost. If the bacteriological 
examination shows the disease not to be true diphtheria, the patient may 
be released from quarantine in two or three days, provided the throat 
symptoms disappear. It is, of course, important that the conditions laid 
down with reference to bacteriological diagnosis shall have been fulfilled. 
Should symptoms continue, however, a second culture should be taken, 
since the bacilli at the first examination may have been so few as to have 
escaped the swab. 

Treatment of children exposed. — When a case of diphtheria occurs in 
a family or an institution every child that has been exposed should receive 
an immunizing dose of antitoxine. Although many points regarding 
immunization are still unsettled, there can be no doubt that for a limited 
time, probably about a month, the serum confers almost complete pro- 
tection. 

Some of the most striking evidences of the value of the serum for 
immunization have been obtained in New York institutions, especially 
in the Nursery and Child's Hospital and the New York Infant Asylum, 
both of which have been under my own observation. The results in these 
institutions, together with those obtained elsewhere, are shown in the ac- 
companying table, which was prepared by Biggs.* 

In the two institutions first named in the table, many infants under 
three months old were injected, and several under a week old, without any- 
thing more than transient disturbances. In one of these institutions 21 
pregnant women and 8 women in the puerperal state were injected ; there 

* The Medical News, November 30, 1895. 



984 



THE SPECIFIC INFECTIOUS DISEASES. 



was no reaction in any of them, and, though the urine was examined 
daily for a week, in none did albumin appear. 

Table Showing the Results of Antitoxine Injections for Immunization. 



Place of Observation. 



New York Infant Asylum 
(1st immunization.) 

New York Infant Asylum 
(2d immunization). 

Nursery and Child's Hos- 
pital. 

New York Juvenile Asy- 
lum. 

New York Catholic Pro- 
tectory. 

Bellevue Hospital 



Health Department in- 
spectors. 



Total, 



Chil- 
dren 
immu- 
nized. 



224 
245 

136 

81 
114 

11 

232 



1,043 



Cases of diph- 
theria develop 
ing among 
those immu- 
nized between 
1 and 30 days. 



1 mild on the 
19th day. 

1 mild on the 
12th day. 








1 mild on the 
19th day. 



Cases 




devel- 


Cases devel- 


oping 


oping after 


within 


30 days. 


24 hrs. 







6 





4 














1 













( 1, 30th. 


3 


3-^ 1, 31st. 




( 1, 55th. 


4 


13 



Number 

of cases of diphtheria 

that occurred in 

the institutions previous 

to immunization. 



107 cases in 108 days. 
6 cases in 12 days. 

46 cases in 90 days. 

15 cases in 18 days, 
j 12 cases ; 3 cases in 
\ 2 days. 
5 cases in 3 days. 

2 cases in 10 days. 

One or more cases in 
more than 90 fam- 
ilies. 



In the Bulletin of the New York Health Department are brought 
together twenty-nine reports, covering 15,986 injections of antitoxine in 
exposed persons for the purpose of immunization. The number attacked 
with diphtheria during the thirty days following injection was but 79, or 
0-5 per cent. Nearly all of these had a mild form of the disease, only one 
case being fatal. Many of these injections were made in the early days of 
antitoxine, and doses now regarded as insufficient were given. 

The dose for immunization is from 50 to 350 units, the former being 
that required for an infant under three months, and the latter for a child 
of twelve or fourteen years ; for one from five to ten years the usual dose 
is 200 to 300 units. With the strongest serum, the larger dose can now 
be administered in a volume of ten minims. 

If possible, cultures should be made from the throats of all exposed 
children, and those having no bacilli should be sent away from the 
house. Children whose throats contain bacilli should be separated from 
others, but not necessarily confined in-doors. Those who are old enough 
should use a gargle of bichloride, 1 to 5,000. For very young children it 
is wise to spray, or better, to syringe the nose with either Seller's or a 
simple saline solution, two or three times a day. The throats of all such 
children should be carefully inspected twice a day. In a hospital the same 
general rules should be adopted. 

Nurses. — Those in charge of diphtheria cases should receive an im- 
munizing dose of antitoxine of 300 or 400 units. As diphtheria is con- 



DIPHTHERIA. 985 

tracted, not from the breath of the patient or the air of the room, but by 
receiving the bacilli into the mouth or air passages, all possible means 
should be taken to destroy the bacilli discharged, and to secure absolute 
cleanliness in everything about the sick-room. Nurses should never be 
allowed to eat or sleep in the sick-room, and an antiseptic gargle should 
be used four or five times a day. The hands should be kept clean, and 
only such dresses worn as can be readily washed and disinfected. It is 
the nurse who is most likely to contract the disease, on account of the con- 
tinued exposure. Hence, these measures should be rigorously insisted 
upon. She should be allowed a few hours in the open air every day. 

Physicians. — The physician should take the same precautions as in 
scarlet fever (page 907). A pocket tongue-depressor should not be used 
for the examination of the throat, but a spoon which is kept in a solution 
of carbolic acid, 1 to 40. In order to prevent the coughing up of mucus 
or membrane in the face of the physician, a pane of ordinary window glass 
may be held in front of the patient's face during inspection of the throat. 

The sick-room. — The carpets, hangings, upholstered furniture, every- 
thing in fact not necessary for the patient's welfare, should be removed, 
especially books, toys, cushions, etc. The room should be a large one, if 
possible with an open fireplace, well ventilated, and fresh air should be 
allowed in abundance. The floor should be washed once a day with a 
solution of bichloride, 1 to 2,000, and dusted often with cloths moistened 
in the same solution. All handkerchiefs, bed linen, and clothing removed 
from the patient should be treated as in a case of scarlet fever. Pieces 
of membrane and other matters discharged from the patient should be 
put into a solution of carbolic acid, 1 to 20, or of bichloride, 1 to 1,000. 
Pieces of old muslin or absorbent cotton should be used to cleanse the nose 
and mouth of the patient and burned immediately. All vessels for the 
reception of expectoration or other discharges should contain bichloride, 
1 to 2,000. The bed-linen should be very frequently changed, and every- 
thing kept scrupulously clean. In the room should be a large bowl of 
carbolic acid, 1 to 40, or some similar solution for the cleansing of hands, 
and a tray of the carbolic solution for spoons, syringes, or other things 
used in the treatment of the patient. All spoons, cups, or other dishes 
used by the patient should be carefully sterilized by boiling for twenty 
minutes. No milk or other food should be allowed to stand about the 
room. There is no objection to the hanging of sheets moistened in car- 
bolic, bichloride, or other disinfectant solutions before the door, but neither 
this nor hanging them about in the sick-room is to be regarded as having 
any value in disinfecting the air of the room. They create a false sense 
of security, and often lead to the neglect of thorough cleanliness, which, 
after all, is the essential thing. 

Disinfection of apartments after an attack should be done as after 
scarlet fever (page 907). 



986 THE SPECIFIC INFECTIOUS DISEASES. 

Treatment. — General measures. — It is important in every case that 
there should be plenty of fresh air in the room throughout the attack. 
Where it is possible, it is desirable to have two rooms for the patient, so 
that he can be changed from one to the other every day, giving time for 
thorough cleanliness and airing. In hospital wards, patients should never 
be crowded together. Small wards, containing three or four beds, are 
much to be preferred to very large ones. Even in mild cases the patient 
should be kept in bed throughout the entire attack, and in severe cases 
this should be continued for some time during convalescence. " It is espe- 
cially important where there have been symptoms of cardiac depression 
during the acute stage. 

Nursing infants may be fed on breast milk obtained by a breast pump, 
but should not be put to the mother's breast. The feeding of older chil- 
dren must be managed very much as in other cases of severe illness (page 
191). Milk is the main reliance ; it should usually be diluted, and for 
younger infants often partially peptonized. The greatest difficulty in 
feeding is seen in the latter part of the disease, when the patients are 
septic and have a strong aversion to food, when vomiting is easily excited 
and when swallowing is difficult on account of the swelling and pain. It 
is then that forced feeding by means of gavage is most valuable. This is 
much more successful with children under three years old than is rectal 
feeding. In children of five or six years, who struggle against the tube in 
the mouth, it may be passed through the nose with very little difficulty. 
The results are, as a rule, extremely satisfactory, and gavage may be used 
with advantage in many intubated cases. 

Stimulants.— -There is no question in regard to the value of alcohol in 
diphtheria. It is altogether the most powerful drug we possess to com- 
bat the effects of the disease upon the nervous centres and the heart. 
Stimulants should be begun as soon as the depressing effects of the poison 
of diphtheria are shown upon the pulse and general condition of the 
patient. In most cases, therefore, they are not needed until the third or 
fourth day ; in a few they may be required from the outset, and in some 
they may not be required at all. The indications for alcoholic stimulants 
are marked prostration, a feeble pulse, and a weak first sound of the 
heart. In regard to the quantity, one ounce of whisky or brandy in 
twenty-four hours is enough to begin with, for a child four years old. 
This should be diluted with at least six parts of water. In very bad 
cases five or six times as much may be given ; the only limit to the 
quantity is the tolerance of the stomach. The method of administration 
should be the same as in other severe acute diseases (page 49). Usually 
stimulants should not be combined with food. A child is more apt 
to rebel against the stimulants than the milk, and it is important that 
nothing be done to interfere with the taking of proper nourishment. 
Other heart stimulants than alcohol, though inferior to it, are of value 



DIPHTHERIA. 987 

in some cases. The most useful one is strychnine, which should be 
given as in pneumonia (page 510). Camphor and carbonate of am- 
monia are valuable for rapid effect in syncopal attacks, and digitalis in 
other cases where the pulse is weak and arterial tension low, but it is 
not wise to give it in large doses. In cases of threatened heart paralysis 
occurring late in the disease or during convalescence, nothing is so valu- 
able as morphine hypodermically. Full doses must be given and repeated 
every two to four hours, so that the child may be kept completely under 
its influence. 

Except for stimulation or the control of special symptoms such as 
vomiting or diarrhoea, all internal medication would better be omitted ; 
for there is yet wanting proof that drugs influence the course or the result 
of the disease. 

Local treatment. — Since the introduction of antitoxine, medical opinion 
has undergone a decided change with reference to local treatment. While 
it is not desirable that it should be entirely abandoned, still it has assumed 
a position of secondary importance ; and under conditions where it can be 
carried out only with great difficulty and the use of considerable force, as 
in the case of very young or intractable children, it is often wise not to 
attempt it systematically. 

The purpose of local treatment, it is now generally agreed, should be 
cleanliness, and not the destruction of bacilli. Cleanliness of the nose, 
mouth, and pharynx is important, inasmuch as one of the chief dangers of 
the disease is the aspiration of bacteria contained in the abundant secre- 
tions of these parts, into the larynx and bronchi. Our aim should there- 
fore be to keep the parts as clean as possible without too severely taxing 
the strength of the child. Harm often results from attempting to do too 
much. 

For cleansing the nose and rhino-pharynx only syringing can be de- 
pended upon. Nasal syringing is indicated when there is much nasal 
discharge, whether membrane is visible in the anterior nares or not, unless 
there is so much resistance on the part of the child that it can not be 
done without a good deal of force. In such cases more harm than good 
may result. However, in septic cases with a profuse fetid discharge it 
may be necessary to syringe the nose, no matter how strongly the child 
resists. Whether it shall be done forcibly in such a case, will depend upon 
the condition of the patient's strength and his pulse. The purpose in 
syringing is not so much to clear the nose, from which absorption is slow 
and imperfect, although this is useful, as to flush the rhino-pharynx, from 
which absorption is always very active. Only bland solutions should be 
employed, such as a common-salt solution, strength of one per cent, or a 
boric-acid solution, one to four per cent strength. 

For ordinary cases, the syringe and the method described on page 57 
may be used. For some cases a fountain syringe possesses manifest ad- 



988 T HE SPECIFIC INFECTIOUS DISEASES. 

vantages, and it is rather more convenient for hospital purposes. All 
solutions should be used lukewarm, and in sufficient quantity to irrigate 
the parts thoroughly, a few such irrigations being much better than a 
great many partial ones. By a skilful nurse syringing can in most cases 
be done with comparatively little disturbance to the child. 

Slight nasal haemorrhages may necessitate less frequent syringing, and 
a free haemorrhage may oblige us to stop it altogether. Astringent solu- 
tions of alum, Monsel's solution, lemon juice, etc., are sometimes bene- 
ficial in such cases, but they must be largely diluted. In children who are 
old enough to use them, the mouth and pharynx should be kept clean by 
gargles. A solution of boric acid, listerine, or Dobell's or Seller's solution 
much diluted, may be employed. 

In cases with a moderate nasal discharge it is usually sufficient to 
syringe three or four times a day ; but in those of the most severe or 
septic type, with very abundant discharge, syringing should be repeated 
as often as every two hours during the day and every four hours at 
night. 

External applications to the throat have practically no effect upon the 
disease, but are often useful to relieve pain and tension in the swollen 
lymph glands. In very young children heat is to be preferred to cold, 
and may be applied either by means of poultices, or, better, spongio- 
piline wrung from very hot water, covered with cotton and then with 
oiled silk ; prolonged poulticing should not, however, be allowed. For 
older children an ice-bag may be used, and this frequently gives great 
relief. 

The Serum Treatment. — This has been the outcome of a long series of 
experiments in which many men have had a share ; but it is to Behring 
pre-eminently that the credit belongs for the development of the princi- 
ples of serum-therapy. It will be sufficient here to indicate the more im- 
portant steps which have led to this discovery. In December, 1890, Beh- 
ring and Kitasato published experiments which demonstrated that it was 
possible for the blood of an immunized animal (one which had been in- 
jected with the toxines of a disease in gradually increasing doses, until a 
condition was reached when such injections produced no reaction) when 
injected into another animal to convey immunity, and also cure the disease 
if artificially produced. This was first shown to be true of tetanus. In 
August, 1892, Behring further showed that the blood of an immunized 
animal had the power both of protecting and curing susceptible animals 
which had been inoculated either with the toxines or with the bacilli of 
diphtheria. Early in the same year he produced from animals his so-called 
" normal " serum, which was used in his animal experiments, this being 
one sixtieth of the strength of his No. 1 serum now employed. The 
further steps consisted in gradually increasing the strength of the serum 
by the use of stronger toxines for injection. Up to this time small ani- 



DIPHTHERIA. 989 

mals had been used, and the serum produced only in limited quantity. 
Later, Eoux conceived the idea of using horses for injection, and from this 
time they were generally employed. In the latter part of 1893 the serum 
was first tried upon diphtheria patients in the Berlin hosijitals, and, 
although it was still very weak, encouraging results were observed. At 
the International Congress held at Rome in March and April, 1894, Heub- 
ner reported his results in cases treated by the serum, followed the same 
month by a report from Ehrlich, Kossel, and Wassermann, with two hun- 
dred and twenty cases, which up to that time had been treated with anti- 
toxine, showing a decided reduction in the death-rate. The results im- 
proved steadily with the strength of the serum employed. By August, 
1894, the beneficial results of the serum were considered sufficiently 
established to warrant placing Behring's serum on sale. The new treat- 
ment attracted but little notice until the Congress at Buda-Pesth in the 
summer of 1894, where Eoux presented a report of three hundred cases 
treated at Paris under his supervision, with results so striking that the 
interest of the entire medical profession was at once aroused. Since the 
beginning of 1895 the serum treatment has been tested on a large scale 
all over the world. 

Regarding the nature of the antitoxine and its mode of action but 
little is as yet definitely known. Two theories have been advanced : one, 
that its action is a chemical one, directly neutralizing the toxine of diph- 
theria ; the other, that its effect is rather a vital one, rendering the cells 
tolerant of the diphtheria toxine. Without being in any sense germi- 
cidal in its effect, the antitoxine produces a condition in the blood which 
arrests the growth of the diphtheria bacillus and the membranous inflam- 
mation which this excites. 

Following the plan of Eoux, the diphtheria antitoxine is produced at 
the present time from the blood-serum of the horse. This is drawn into 
sterilized vessels and preserved in small sterilized bottles, each of which is 
designed to contain a sufficient quantity for a single dose. It is preserved 
by the addition of carbolic acid (Behring), camphor (Roux, New York 
Health Department, and others), or some other antiseptic. Properly pre- 
pared, it will keep without deterioration for from three to six months; 
but after one year it loses somewhat of its antitoxic properties, this 
amounting, according to the experiments of Park, to perhaps one third 
of its original strength. It should be kept in a cool, dark place, and after 
a bottle has been opened it should be used within a few days. The effort 
to prepare and preserve the antitoxine in a dry form has not thus far been 
very successful. 

The strength of the serum is measured in antitoxine units, the unit 
being an arbitrary one and representing the ability to neutralize a definite 
quantity of diphtheria toxine. The improvements in the production of 
the serum have thus far consisted in increasing its strength. Behring's 



990 THE SPECIFIC INFECTIOUS DISEASES. 

normal serum as first used contained in each cubic centimetre (15 minims) 
one antitoxine unit ; that sold as Behring's No. 3 contains 150 units in 
each cubic centimetre. The New York Health Department have now 
placed on sale a serum containing 500 units in each cubic centimetre, and 
have produced one containing 750 units in each cubic centimetre. There 
may now be obtained also an " extra-potent " Behring's serum which con- 
tains 500 units in each cubic centimetre. The stronger serum has been 
produced by the use of stronger toxines for animal injections, those at 
present employed being many times stronger than those formerly regarded 
as the strongest possible. 

The concentration of the serum is of immense advantage, and has sim- 
plified many things in connection with its administration. Horse-serum 
being merely the vehicle of the antitoxine, and itself, it is believed, capable 
of producing unpleasant effects when large quantities are injected, it is 
desirable to administer the dose of antitoxine in the smallest amount of 
serum possible. There seems now to be good evidence that the local dis- 
comfort — oedema, pain, etc. — and also the various eruptions, which some- 
times follow its use, have depended largely upon the amount of horse- 
serum injected. With the concentrated serum now available, it is never 
necessary to use more than 5 cubic centimetres (75 minims) for a single 
dose, and usually but half this quantity. This does away with the neces- 
sity for large and special syringes. The hypodermic syringe as made for 
veterinary use, holding 5 cubic centimetres, answers every purpose, and 
is, I think, to be preferred on account of the smaller size of the needle. 
For nearly a year I have used no other instrument. The syringe should 
be rinsed with alcohol immediately before using, and the needles should 
always be boiled. Care should be taken that all air is expelled from the 
syringe before the injection is made. The seat of injection is of com- 
paratively little importance now that the dose of antitoxine can be given 
in so small a volume. The cellular tissue of the abdomen or the thigh is 
perhaps the best location. If a small needle is used, no application of 
adhesive plaster is necessary ; but the needle puncture should be covered 
with the finger for a few moments. 

Rules for accurate dosage in antitoxine are as yet impossible. It is 
desirable to give in every case enough to neutralize the amount of diph- 
theria toxine present in the blood, but we have no very exact means of 
determining how much this is. It depends upon the virulence of the 
bacilli — which may be judged by the severity of the attack and the extent 
of the membrane — the time when the injection is made, and somewhat 
upon the age of the patient. The general experience of the profession 
thus far is, that for children over two years old the initial dose should be 
from 1,500 to 2,000 units in all severe cases, including those of laryngeal 
stenosis, this dose to be repeated in from eighteen to twenty-four hours if 
no improvement is seen, and again in twenty-four hours if the course of the 



DIPHTHERIA. 991 

disease is unfavourable. The third dose is rarely necessary. Exceptional 
cases of great severity, especially when seen late, should receive somewhat 
larger doses than those mentioned — i. e., 3,000 units. Mild cases should 
receive 1,000 units for the first injection, a second being rarely required. 
For children under two years old, the initial dose in a severe case or one 
of laryngeal stenosis should be 1,000 units, to be repeated as above indi- 
cated ; in a mild case, 600 units. The most concentrated serum is to be 
preferred, and only that obtained from a reliable source should be used. 
It is unfortunate that legal restrictions do not make it impossible for any 
other to be sold. My own experience has been chiefly with the serum of 
Behring and that of the New York Health Department, both of which 
are absolutely reliable, as are also the serum of Mulford and that of Parke, 
Davis & Co. 

Not only must a sufficient dose be given, but, to be efficient, the anti- 
toxine must be administered early in the disease before the diphtheria 
toxines have done their work. The serum can not undo the serious dam- 
age already done to the cells of the body, and this at the time of injection 
may be so great that death will result. One who waits until his cases 
have grown alarmingly worse under other treatment and gives but half 
doses, will see little benefit from antitoxine. In very mild cases, with 
older children, one may wait for the result of a bacteriological examination, 
where such examinations are possible, but never in a severe case and never 
in a young child. In the group of severe cases should be placed every one 
which at the first visit shows a pharyngeal exudate covering more than the 
tonsils, also all cases with symptoms of laryngeal invasion, and all with an 
exudate in the pharynx and a profuse nasal discharge. If in a doubtful 
case twelve hours' observation shows that the membrane has spread from 
its original seat, no further delay is admissible. Experiments have shown 
that after a fatal dose of diphtheria toxine, an animal can usually be res- 
cued if the antitoxine is administered within forty-eight hours, but rarely 
after that time. In human diphtheria marked benefit usually follows in- 
jections made as late as the third day; but after three days have passed 
little benefit is to be expected, although it occasionally follows even later 
injections. On the other hand, in very severe or in malignant cases irre- 
parable harm may be done by the disease during the first twenty-four 
hours. 

The local effects of the injection are a slight redness, pain, and usually 
some transient oedema. General eruptions are seen in a considerable num- 
ber of cases, from five to forty per cent according to various observers. 
They are most frequent from the eighth to the twelfth day after injec- 
tion, usually appearing in the form of an urticaria. Although in most 
cases slight and transient, the body may be covered and the urticaria con- 
tinue to be most annoying for several days. Various forms of erythema 
have been occasionally observed, and in a few cases swelling of the joints. 



992 THE SPECIFIC INFECTIOUS DISEASES. 

There appears to be a close connection between the amount of horse- 
serum administered and the occurrence of these symptoms. They are 
certainly much less frequent since the use of more concentrated anti- 
toxine. 

The effect upon the diphtheritic membrane is usually noticeable within 
twenty-four hours ; it first stops spreading, and soon begins to soften and 
loosen. The swelling of the mucous membrane subsides and the local 
disease abates, very much after the manner seen when the disease runs 
its usual course. The striking thing after the use of antitoxine is the 
rapidity with which these changes take place, and the abrupt transition 
from an advancing to a retrograde process. The evidence of the subsi- 
dence of the inflammatory conditions in the larynx and trachea is quite as 
marked as in the pharynx. The symptoms of stenosis, even when severe, 
often diminish in a few hours arid continue to improve, making operation 
unnecessary in a very large number of cases where previously it seemed 
inevitable. The membrane loosens rapidly in the larynx and trachea, 
sometimes necessitating the frequent removal of the intubation tube, 
where operation has been performed. It is the experience of McNaugh- 
ton (Brooklyn), and of some other operators, that the tube is more fre- 
quently coughed up after the use of antitoxine than formerly, probably 
because of the rapid subsidence of the swelling. Improvement is also 
shown by the cessation of the nasal discharge, the re-establishment of 
nasal respiration, and the diminution in the swelling of the glands of 
the neck. 

The effect upon the constitutional symptoms is not less striking. In 
favourable cases there is seen, often in twelve hours, a fall in temperature 
and improvement in the pulse and in the nervous condition of the patient. 
Sometimes the change in the general symptoms is seen earlier than in the 
local conditions. 

The limitations of antitoxine. — It is important that these should al- 
ways be kept in mind. The serum must be given early, for if given late 
it can not undo the mischief already done by the diphtheria toxine. Cases 
of great severity have often passed the period when recovery was possible, 
before the antitoxine is given. This period may in some cases be three 
days, in others it may be less than twelve hours. The tissues most sus- 
ceptible to the diphtheria toxine are probably the nervous structures, the 
heart, and the kidneys ; and the consequences of its action may be seen in 
the production of nephritis, in sudden heart failure at the height of the 
disease, or some form of post-diphtheritic paralysis, in spite of the fact 
that antitoxine was given at a period early enough to avert death from 
local disease in the larynx or bronchi. Again, antitoxine is of no value in 
cases of streptococcus septicemia. The early arrest of the inflammation 
excited by the diphtheria bacillus is unfavourable to the spread of. strepto- 
coccus infection, yet sometimes the latter has gained such headway or is 



DIPHTHERIA. 993 

of such intensity as to involve almost the entire body. Against the phleg- 
monous inflammation of the throat or the cellular tissue of the neck, 
broncho-pneumonia, and nephritis, antitoxine is powerless; and just in 
proportion to the severity of these inflammations are negative results 
seen. 

Real and alleged dangers from antitoxine injections. — In the cases 
where sudden death has followed antitoxine injections, the evidence that 
antitoxine was the cause of death is not conclusive. That only three or 
four alleged instances of this have occurred among the hundreds of thou- 
sands of antitoxine injections which have now been made, is sufficient to 
establish the fact that the serum itself is harmless. These rare accidents 
have been attributed to the carbolic acid used to preserve the antitoxine, 
to the injection of air,* to the shock from needle puncture, and to indi- 
vidual idiosyncrasy. 

Kegarding the unfavourable effects upon the heart, the kidneys, and 
the blood, attributed to antitoxine, they are to my mind not proved. In a 
disease like diphtheria, where the heart and kidneys are so often and so 
seriously affected, and where cardiac and renal symptoms in so many cases 
are so suddenly manifested, it is impossible to say, even when such symp- 
toms follow the injection of serum, that they are not due to the original 
disease. They were seen with great frequency before antitoxine was heard 
of. It is, however, not impossible that in a very young or delicate child 
the sudden introduction into the circulation of such a large quantity of 
horse-serum as was first used (i. e., 20 or 30 cubic centimetres) might in- 
tensify existing cardiac or renal disturbance — a result not probable and I 
think not reported with the concentrated serum now in use. Observa- 
tions regarding the effect of the serum upon the blood were made by 
Billings, Jr., upon twenty-nine cases of diphtheria. He found the re- 
duction both in the haemoglobin and the red cells to be much less than 
the average found in cases of diphtheria of similar severity not treated 
by the serum. 

At the present time, after the serum has been in general use for nearly 
two years, no evidence has been adduced as to its danger or injurious 
effects which should deter any one from its use. Those which have been 
reported are to be looked upon in the light of accidents for which the 
antitoxine was probably not responsible. 

The results with antitoxine in hospital practice. — Guerard, in Bulletin 
No. 3 of the New York Health Department, has collected reports of 9,893 
cases treated with the serum, with an average mortality of 18*3 per cent. 
Of these cases, 7,277, in which the mortality was 20 per cent, were re- 
turned by 53 hospitals ; the reports from the same hospitals give as their 
previous mortality an average of 44-3 per cent. The accompanying chart 

* Seibert and Schwyzer, New York Medical Journal, May 30, 189G. 
73 



994 



THE SPECIFIC INFECTIOUS DISEASES. 



(Fig. 166) shows the results obtained in the Children's Hospital, Berlin, 
with and without the serum. 



MORT- 
ALITY 


AGES 


80$ 
75$ 
70$ 
65$ 
60$ 
55$ 
50$ 
45$ 
40$ 
35$ 
30$ 
25$ 
20$ 
15$ 
10$ 
5$ 


0-2 


2-4 


4-6 


6-8 


8-10 


10-12 


12-14 
















r* 














c i 


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z~z^z 


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Fig. 166. — Chart showing the percentage mortality from diphtheria in the Children's Hospital, 
Berlin, for three periods : a, a, for four years before the introduction of the serum ; b, 6, for 
the first year of the serum treatment ; c, c, for two months during that year when the supply 
of serum failed. (After Baginsky.) 

The fact that during August and September of the first antitoxine 
year, when the supply of serum became exhausted, the death-rate rose at 
once to nearly three times what it had been, and fell again when the serum 
was again in use, is one of the most striking demonstrations yet published 
in favour of the serum. Identical experiences are reported by Korte, 
Heim, and Ganghofner, all showing that the results were not explained 
by a milder form of the disease, for when antitoxine was omitted the same 
mortality prevailed as had been formerly observed. 

Results in 'private practice. — The largest number of cases from this 
source has been brought together in the Collective Investigation made by 
the American Pediatric Society.* This embraces 5,794 returned by 615 
physicians from 114 cities and towns in America, with an average mortal- 
ity of 12*3 per cent. But in this report is included every case returned 
in which the serum was given, many of which were moribund at the time 
of injection, the serum being used only to gratify parents. If these cases 
and those dying within twenty-four hours after the first injection be 
excluded, there remain 5,576 cases, with a mortality of 8-8 per cent. Of 
4,120 injected during the first three days the mortality was 7*3 per cent, 
or, excluding moribund cases and those dying twenty-four hours after the 



* Archives of Paediatrics, July, 1896. 



DIPHTHERIA. 



995 



first injection, but 4*8 per cent. The diagnosis of diphtheria was con- 
firmed by a bacteriological examination in 83 per cent of these cases ; in 
the remainder it rested upon the clinical symptoms. 

Influence of the serum upon the diphtheria mortality in cities. — If 
Behring's antitoxine is the specific remedy for diphtheria that it is 
claimed to be, its general use should produce a decided fall in the actual 
mortality from diphtheria. We will take the figures from four large 
cities — New York, Berlin, Paris, and Chicago; from the first three we 
have full reports not only of the antitoxine period, but of several years 
preceding. 

In the city of Paris, during the six years preceding the use of antitox- 
ine (1889 to 1894 inclusive), the average number of deaths from diph- 
theria and croup was 1,518 ; the minimum number was 1,009, this being 
in 1894, during the last four months of which antitoxine was in general 
use. During the first year of antitoxine (1895) the number of deaths fell 
to 442, or considerably less than one half the mortality of any previous 
year during the period considered. 

The following table gives the number of deaths per month for the first 
three months of the six years before, and the two years after the introduc- 
tion of the serum : * 



City. 


Average 
monthly mor- 
tality, 1889-'94, 
without serum. 


Minimum 
monthly mor- 
tality, same 
period. 


1895. 
With serum. 


1896. 
With serum. 


( January 


160 
152 
180 
135 
117 
114 
317 
276 
236 


120 (1892) 
108 (1893) 
148 (1894) 

102 (1891) 

103 (1891) 
86 (1891) 


48 

47 

45 

79 

64 

88 

207 

171 

168 


47 


Paris -| February 


56 


( March 


48 


( January 


58 


Berlin -1 February 


54 


( March 


47 


xt tt i ( January. . 


181 






172 


(^^•(S!!: :::::::::: 




165 









The only month in which a lower mortality occurred without anti- 
toxine than with it was in Berlin, in March, 1891 ; but it will be seen that 
the amount of diphtheria in the city that year was much less than the 
average, as is indicated by the figures for January and February. 

The following chart (Fig. 167) shows even better than the table the 
influence of the introduction of antitoxine. Had the serum been em- 
ployed to the same extent in all the cities, we should doubtless see a cor- 
responding reduction in the number of deaths in all. But, as is well 
known, the serum was much more generally employed in Paris than in 
either of the other cities. 



* These figures are taken from the advance sheets of Bulletin No. 3 of the New 
York Health Department, placed at ray disposal by Dr. II. M. Biggs. 



996 



THE SPECIFIC INFECTIOUS DISEASES. 





1886 '87 '88 '89 '90 '91 '92 '93 '94 "95 




200 

190 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 
























200 

190 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 

20 
























New 


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\ 






















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Berlin 
























\ 






















\ 
















New 


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Paris 




1886 "87 '88 '89 '90 '91 '92 '93 '94 '95 





Fjg. 167. — Chart showing deaths from diphtheria and croup per 100,000 of population in New- 
York, Berlin, and Paris. During the last half of 1894 antitoxine was widely used in Berlin, 
and during the last four months of that year it was in general use in Paris. It will be noted 
that the only time during the period when the lines of the three cities correspond, is since 
the use of the antitoxine. (From Bulletin No. 3, New York Health Department.) 



The results in the city of Chicago are quite as striking as # those in 
Paris, and are shown by the accompanying chart (Fig. 168), which dem- 
onstrates how a rapidly rising death-rate was checked by the introduc- 
tion of the serum in October, 1895. 

The lines for both years show a relatively small number of deaths dur- 
ing the summer, but a rapid increase in the autumn months. It will be 
noted that during every month of the second year up to and including 
October, there was an increase in the fatal cases over the previous year, 



DIPHTHERIA. 



997 



and that in October the daily death-rate was 81a day, as against 5 -5 the 
previous year. The epidemic of diphtheria at this time had attained such 
proportions in the city that the question of closing all the public schools 
was considered. In the latter part of October the Health Department 
brought antitoxine into general use by establishing sixty stations through- 
out the city where it could be obtained, and organizing a special corps of 
physicians to visit the diphtheria cases. One of these was sent to every 
case in a tenement house, and the serum injected unless refused by the 
parents. The effect upon this daily death-rate is graphically shown in 
the chart. Of 1,468 cases treated by the inspectors, the mortality was 
but 6*4 per cent ; and of 1,112 cases injected during the first three days, 
but 2*5 per cent. 





APRIL 


MAY 


JUNE 


JULY 


AUG. 


SEPT. 


OCT. 


NOV. 


DEC. 


JAN. 


FEB. 


MAR. 


PER 
DIEM 

9 
8 
7 
6 
5 
4 
3 
2 






































































































































/s 
























/ 


\^e-— 


— """*"" -J 


-, 


















/ 






















, 
























/ 


/ 






- 
















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11 *— ~_ 




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Fig. 168. — Showing the average daily mortality from diphtheria in Chicago for two years. The 
dotted line, b, b, indicates the mortality from April. 1894, to April, 1895; the line a, «, the 
mortality from April, 1895, to April, 189P>. Antitoxine was introduced at the close of Octo- 
ber. (From the Report of the Health Department.) 

Eesults in other American cities have been no less striking. In the 
city of Newark, K". J., there were reported to the Board of Health, from 
June 20, 1895, to March 20, 1896, 939 cases of diphtheria ; 606 of these 
were treated by the serum, with 85 deaths, a mortality of 14 per cent ; 333 
cases did not receive the serum, and among these there were 138 deaths, a 
mortality of 41-4. 

In the city of Boston, Ernst reports 1,156 cases treated by the serum, 
with 165 deaths, a mortality of 14*2 per cent. The report by MacCullom 
from the diphtheria wards of the Boston City Hospital shows even better 
results. Of 844 cases treated by the serum, there were 96 deaths, a mor- 
tality of 11 per cent; the previous mortality in the same institution with- 
out serum was 40 per cent. 

The results as modified by the time of injection and the age of the 
patients. — The statement has been already made that striking improve- 
ment from the use of the serum is seen only when it is used early. In 
the American Pediatric Society's report the mortality of 4,120 cases 
injected during the first three days was 7*3 per cent, including even 
those which were moribund at the time of injection ; of 758 cases in- 



998 THE SPECIFIC INFECTIOUS DISEASES. 

jected on the fourth day the mortality was 20*7 per cent; and of 690 
injected later than the fourth day it was 35*3 per cent. The figures 
are from private practice. The statistics from diphtheria hospitals show 
approximately the same variation, but the percentages are all slightly 
higher. 

It has been the experience of nearly every one, that the greatest reduc- 
tion in mortality is seen in the youngest patients. In the above report 
the mortality of 867 cases two years old and under, was 233 per cent; 
while, excluding moribund cases and those dying within twenty-four hours 
of the first injection, it was. only 19*2 per cent. There are two factors in 
this great reduction from former figures. These infants are patients for 
whom often little or nothing could be done by local treatment, and in 
whom broncho-pneumonia was almost certain to follow the invasion of 
the larynx. The serum enables us largely to dispense with local treat- 
ment, and when used early in the great majority of cases it prevents the 
extension of membrane below the larynx. 

The results in laryngeal cases. — The allegation that the favourable re- 
sults obtained with the serum are to be explained by the mildness of the 
disease can not be applied to diphtheria of the larynx. These cases are not 
mild, nor do they tend to spontaneous recovery ; furthermore, the results 
obtained both by intubation and tracheotomy without antitoxine are well 
known. Laryngeal diphtheria therefore furnishes the crucial test of the 
serum treatment. The benefits of the serum are seen, first, in the num- 
ber of cases that recover without operation ; secondly, in the percentage 
of recoveries in operative "cases ; thirdly, in the shortening of the time that 
the tube is necessary. 

It is not yet possible to give exact figures regarding the proportion 
of laryngeal cases that recover without operation. Baginsky found that 
during the two months in which the serum treatment was interrupted in 
the Childrens' Hospital in Berlin, because the supply was exhausted, the 
proportion of cases requiring operation was 55*2 per cent, while with the 
serum, during the period immediately preceding and following this, it 
was only 18*1 per cent. This is to be explained partly by the fact that by 
the early use of the antitoxine the larynx less frequently became involved, 
and partly by the number of laryngeal cases recovering without opera- 
tion. 

In the Pediatric Society's report there were 1,256 laryngeal cases, of 
which 554 recovered without operation. Welch's paper* contains figures 
from seven European observers with reference to this point, who together 
report in 401 laryngeal cases, 27*2 per cent of recoveries without opera- 
tion. The improvement in the results of operated cases are even more 
striking" : 



Transactions of the Association of American Physicians, 1895. 



DIPHTHERIA. 



999 



Results from Intubation icith and without Antitoxine. 



Source. 



Ranke, European hospitals 

Welch, European hospitals 

McXaughton and Maddren, private prac- 
tice in America 

American Pediatric Society's Report, pri- 
vate practice in America 

Dillon Brown, private practice, with calo- 
mel fumigations 

Reports of operators with experience of 10 
cases or more, in American Peediatric 
Society's Report 



Cases. 


Mortality. 


1,445 
342 


62-5 

29-8 


5,346 


69-4 


533 


25-9 


279 


49-4 


280 


23-2 



Without antitoxine. 
With 



Without 

With 

Without 

With 



O'Dwyer says of his last 100 operations, that the first 70 without 
the serum gave a mortality of 73 per cent, the last 30 with the serum a 
mortality of 33-3 per cent. McNaughton says that in his last 72 opera- 
tions without serum the mortality was 66*6 per cent; the first 72 with 
serum, 33 3 per cent. 

It is useless to multiply evidence, for from all parts of the world the 
testimony is the same, that the mortality in cases of laryngeal-diphtheria 
requiring operation has been reduced at least one half by the introduction 
of serum. This marked improvement is due to two causes : the serum 
shortens very materially the length of time it is necessary to wear the 
tube ; and, what is far more important, it prevents the extension of the 
membrane downward into the trachea and bronchi, in this way removing 
in great measure the danger of broncho-pneumonia. 

The results from tracheotomy have likewise been greatly improved by 
the serum, although not to the same degree as those from intubation. A 
collection of 23,941 tracheotomies for croup by Prescott and Goodthwait * 
gives a mortality of 71*3 per cent. Of 873 tracheotomies with serum f 
the mortality was 40*9 per cent. It is now generally conceded, not only 
in America but all over the continent of Europe, that as a primary opera- 
tion intubation should always be performed, tracheotomy being reserved 
for the rare cases in which intubation has failed to relieve the stenosis. 

Summary. — 1. Behring's antitoxine is a specific remedy for experi- 
mental diphtheria in animals. 

2. Experience is now sufficient to justify the statement that it is so in 
man, and just in the degree to which we can fulfil the conditions which 
are essential in experimental diphtheria. 

3. These conditions are, that the serum must be administered early — 
usually within forty-eight and certainly within seventy-two hours — that 
the dose be adequate, and the case be one of pure diphtheria. 



* Gillet, Sero-therapie, Paris, 1895. 

f Guerard's collection, in New York Health Board Bullet in. 



1000 THE SPECIFIC INFECTIOUS DISEASES. 

4. Experience shows the serum to be much less efficacious in cases of 
so-called mixed infection or septic diphtheria, and that it is valueless in 
membranous inflammations which are due to streptococci — i. e., pseudo- 
diphtheria. 

5. The serum itself is essentially harmless both when injected in 
healthy persons for immunization, or in those suffering from diphtheria. 
Serious symptoms following injections are so exceedingly rare that they 
must be attributed to other causes. 

G. Unpleasant symptoms, rashes, etc., have a close relation to the 
volume of serum injected, and with the concentrated preparations now 
available they have become much less frequent. 

7. In a young child the serum should be injected upon a clinical diag- 
nosis of diphtheria without waiting for a bacteriological confirmation. 

8. In older children one may wait for this in a mild case, but never in 
a severe one, particularly a laryngeal case. 

9. For all cases, but especially for young children, the most concen- 
trated preparation of antitoxine which can be obtained should be employed. 

10. From the most trustworthy statistics which are now available, it 
appears that the actual mortality from diphtheria (including membranous, 
croup) has been reduced at least one half by the general adoption of the 
serum treatment ; and 

11. That in cases injected during the first two days the mortality is 
less than five per cent. 

12. The evidence is conclusive that in laryngeal diphtheria the serum 
in sufficient doses largely prevents the extension of membrane into the 
trachea and bronchi, and thus prevents broncho-pneumonia. 

13. There are not yet sufficient data at hand to enable one to state to 
what degree the heart, the kidneys, and the nervous system are protected 
by the serum. It is, however, certain, that to insure protection of the 
nervous system, the injection must be made very early. 

14. While much still remains to be learned regarding immunization, 
present knowledge justifies the statement that for a period — approximately 
a month — the protection conferred is practically complete. Immunizing 
doses should therefore be given to every child in an infected, household or 
institution. 

15. Gratifying as were the earlier results with the serum treatment, 
they have been constantly improving, and there is every reason to believe 
that, with larger experience both in its preparation and its use, still better 
results will yet be reached. Certainly there is no remedy for any disease 
that has more testimony in its favour than has now antitoxine for diph- 
theria. 

Other treatment in connection with antitoxine. — In the mild cases 
nothing else is required except to keep the child in bed and to continue a 
fluid diet. In the severe cases, heart stimulants, especially alcohol aud 



DIPHTHERIA. 1001 

strychnine, are to be used as formerly, according to the condition of the 
pulse. Nasal injections of bland fluids, either a warm salt solution or five- 
per-cent boric acid, should be used every three or four hours in severe 
nasal or naso-pharyngeal cases, unless the child is very young or intract- 
able, but if he struggles much against them more harm than good is 
likely to result from their continuance. The mouth should be kept clean 
by the use of an antiseptic mouth-wash, such as Seller's solution, or, in 
the case of older children, by a gargle of bichloride 1 to 10,000. A fluid 
diet, careful nursing, and absolute quiet are the only other measures that 
can be regarded as essential. The use of strong antiseptic or caustic 
applications, whether by the spray, swab, or syringe, for the purpose of 
controlling the local disease, should be entirely omitted. The heart and 
the kidneys should be watched in all cases, not only during the disease 
but for some time after it. 

Convalescence. — After a severe attack of diphtheria convalescence is 
always slow on account of the anaemia and the depressing effects of the 
disease. Patients should invariably be kept in bed for at least a week 
after the throat has cleared, and longer if any tendency to cardiac weak- 
ness is seen. The pulse should be carefully watched, and irregularity, 
intermission, dicrotism, or a weak first sound of the heart, should make 
one apprehensive. An abnormally slow pulse may be more* serious than 
one which is rapid. Under such circumstances the patient should be kept 
recumbent and absolutely quiet, since sudden and even fatal syncope may 
be the result of the violation of these rules. 

The extreme degree of anaemia requires that iron be given for a con- 
siderable time during convalescence, to be followed by cod-liver oil, wine, 
and other tonics. 

Great difficulty is occasionally experienced in getting rid of the bacilli 
in the throat. Inasmuch as it is now generally made a condition of re- 
lease from quarantine that the throat shall have been shown by cultures to 
be free from bacilli, this becomes a matter of much importance. « The 
tonsillar crypts and the adenoid tissue of the rhino-pharynx are the places 
where bacilli are likely to remain. The most efficient means appears to 
be, to syringe the nose four or five times daily with a solution of bichloride, 
1 to 5,000, to which one eighth glycerin has been added, and to use the 
same solution as a gargle. For children under four years old a simple 
salt solution, or a dilute Dobell's solution, should be substituted and the 
gargle omitted. 



1002 THE SPECIFIC INFECTIOUS DISEASES. 



PSEUDO-DIPHTHERIA. 

Synonyms: False diphtheria, streptococcus diphtheria, scarlatinal diphtheria, 
diphtheroid inflammation, croupous tonsillitis. 

At the present time there are included under the term pseudo-diph- 
theria all inflammations of the throat and upper air passages character- 
ized by the production of a false membrane, in which the Loeffler bacil- 
lus is not found. When these inflammations are primary they are rarely 
serious ; but when they complicate scarlet fever or measles they may be 
very severe, and frequently prove fatal. 

Frequency. — Numerical statements regarding the relative frequency of 
this disease and true diphtheria signify very little, because of the varia- 
ble conditions under which observations have been made. From the in- 
vestigations of Park, Baginsky, Martin, Morse, and others, it would appear 
that in from twenty-five to thirty-five per cent of the cases formerly 
sent to hospitals with a clinical diagnosis of diphtheria, the disease was 
pseudo-diphtheria. Most of these were mild, and were then regarded 
by many physicians as simply cases of tonsillitis, the exceptions being 
those which were secondary to scarlet fever or measles. 

Of the membranous inflammations occurring in the diseases just men- 
tioned, the great majority are examples of pseudo-diphtheria. Of seven 
cases of membranous angina in measles and three in scarlet fever, studied 
by Prudden, all were proven to be pseudo-diphtheria; of nineteen occur- 
ring with scarlatina, studied by Park, only two were found to be true 
diphtheria; and of sixteen occurring with scarlet fever and three with 
measles, studied by Booker, none were true diphtheria. The observa- 
tions made along the same lines by Sorenson, Wurtz and Bourges and 
others have confirmed the results obtained upon this side of the Atlantic. 
It has been the general experience of all writers that when it compli- 
cates the diseases mentioned, pseudo-diphtheria occurs, as a rule, at 
the height of the primary disease, sometimes preceding the eruption, 
while true diphtheria more often occurs later, even during convalescence. 

Etiology. — As was first shown by Prudden in 1888, and abundantly 
confirmed by others since that time, this inflammation is usually due to 
the streptococcus pyogenes; it may be found alone, or associated with 
the staphylococcus aureus or albus, and occasionally the staphylococcus 
may be found alone. 

The streptococcus is very frequently found in the throats of healthy 
persons, particularly at certain seasons in cities, and in children who live in 
tenements or who are inmates of hospitals or other institutions. The local 
conditions in the mucous membranes during an attack of measles, scarlet 
fever, and other infectious diseases, are especially favourable for the devel- 



PSEUDO-DIPHTHERIA. 1003 

opment of these germs, which at such times are very often present in great 
numbers even when.no membrane is seen. 

Bad drainage and sewer-gas poisoning are other conditions with which 
this form of sore throat often exists, and a predisposition is afforded by 
unhygienic surroundings of any description. From the fact that the 
streptococcus is so widely distributed, attacks of pseudo-diphtheria may 
occur in any place and at any time, irrespective of epidemic influences or 
even the occurrence of other cases. 

To what degree these cases are to be regarded as communicable, and 
what precautions regarding isolation and disinfection are required, are 
questions of much importance. The most extensive investigations upon 
these points are those made by the New York Health Department.* As a 
result of observations upon 450 cases which were followed, the conclusion 
was reached that the disease was so slightly contagious (if at all), and 
usually so mild, that strict isolation and subsequent disinfection were un- 
necessary. Of 113 cases occurring in 100 families, in only 14 was there a 
history of exposure to a similar case ; and in only 9 was there another case 
in the same family. In many of the latter, a common origin appeared 
more probable than that one case was derived from another. 

At the present time the general opinion of the profession seems to be 
that these cases are to a slight degree communicable, to be compared in 
this respect to ordinary catarrhal colds or possibly to pneumonia. They 
are probably more contagious in the presence of the poison of scarlet fever 
or measles. 

Lesions. — In the primary cases the membrane is generally con- 
fined to the tonsils or is chiefly there, there being only small deposits 
elsewhere. In the secondary cases, the entire pharynx may be covered and 
the disease may extend to the nose, the mouth, the middle ear, and occa- 
sionally to the larynx, trachea, and bronchi. 

The structure of the membrane resembles that of true diphtheria, 
and it is impossible by a microscopical examination alone always to 
separate the two diseases. In many cases the membrane is softer, more 
friable, and contains a relatively larger number of cells than does that of 
true diphtheria, but the structure of the latter varies so much that it is 
not safe to draw any positive conclusions. 

In the mild cases the inflammation of the mucous membrane is a 
superficial one and the false membrane is not very adherent. In the 
severe cases, chiefly the secondary ones, the process extends much deeper. 
There are usually seen only congestion, cedema, and cell infiltration, but 
deep suppuration, and even extensive necrosis may take place. This usu- 
ally occurs in the tonsils, palate, uvula, or epiglottis ; but it may extend 
to the tissues of the pharynx and into the cellular tissue of the neck. The 

* Scientific Bulletin, No. 1. 



1004 THE SPECIFIC INFECTIOUS DISEASES. 

lymph nodes are swollen in all the severe cases, and often the inflamma- 
tion ends in suppuration. 

The streptococci are found in the false membrane, in the underlying 
mucous membrane, in the lymph spaces and in the lymph nodes. In the 
most severe cases there are present the lesions of a general streptococcus 
infection. The blood swarms with these germs, and they may set up in- 
flammations in any of the organs, but especially in the lungs and the 
kidneys, less frequently the serous membranes. Small foci of suppura- 
tion may be found in any of the viscera. 

Symptoms. — 1. The primary cases. — The onset is usually sudden, with 
well-marked symptoms : there are frequently chilly sensations, headache, 
vomiting, general pains, and in most cases the child complains of soreness 
of the throat and pain on swallowing. There are first seen a general red- 
ness and swelling of the tonsils, sometimes of the entire pharynx ; shortly 
afterward membranous patches appear upon the tonsils. These vary 
greatly in appearance. In colour they are yellow or gray, often changing 
later to a dirty-olive tint. (Plate XVII, c.) The membrane seems loose- 
ly attached and can frequently be wiped off with a swab. It is soft and 
friable, very rarely thick, firm, or tenacious. It is often irregular in its 
outline, which is not sharply defined. The membrane usually remains 
but three or four days and disappears rapidly. As a rule, it is limited to 
the tonsils, and does not spread after it first forms. Occasionally, how- 
ever, small patches are also seen upon the fauces or the pharynx. The 
oedema and other evidences of inflammation in the throat are usually 
more marked than in true diphtheria, and the swelling of the lymph 
nodes behind the jaw is slight. The constitutional symptoms are gener- 
ally more severe during the first two days, and the temperature may be 
103° or 104° R, but by the third day it falls, and most of the symptoms 
subside. It is rare for the disease to extend either to the nose or the 
larynx. Generally there are no complications and no sequelae. 

2. The secondary cases. — Some of these are mild, and do not differ 
from those just described, but most of the severe cases are included in this 
group. The clinical picture of the latter is that of scarlatina a?igi?iosa, 
as given by the older writers, and it does not differ in any essential par- 
ticulars from the septic form of true diphtheria (page 969). The local 
symptoms are those of severe pharyngeal diphtheria, and the constitu- 
tional symptoms those of septicaemia. 

"When the disease complicates scarlet fever, the symptoms may precede 
the eruption, but they usually begin at the height of the primary fever — i. e., 
from the second to the fourth day — and gradually increase in severity, 
reaching their maximum from the fifth to the eighth day of the disease. 
In measles the throat symptoms are somewhat later ; they begin at the 
height of the primary fever, and often increase while the eruption fades. 
In nearly all severe scarlatinal cases the disease involves the nose and the 



PSEUDO-DIPHTHERIA. 



1005 



middle ear. In measles both these complications are less frequent, but 
there is a much greater tendency to involve the larynx, and if the larynx 
in a young child the process is almost invariably complicated by broncho- 
pneumonia. In some cases the larynx is invaded when there is no mem- 
brane in the pharynx ; but this is very infrequent, unless the disease is true 
diphtheria. Catarrhal laryngitis in a young child may produce symptoms 
which are practically identical with those of the membranous form, and 
there is little doubt that many cases complicating measles in which the 
latter diagnosis is made are really examples of catarrhal laryngitis, par- 
ticularly if no membrane is visible in the throat. 

Secondary cases as a class are characterized by high temperature (Fig. 
169), rapid, feeble pulse, great prostration, and delirium, apathy or stupor, 
and often albuminuria. In fatal cases death usually occurs at the height 
of the disease, from asthenia, broncho-pneumonia, or nephritis, sometimes 




Fig. 1(59.— Pseudo-diphtheria following measles. The chart "begins at the time of the full erup- 
tion in a severe case of measles. On third day temperature fell, with fading eruption, and 
child seemed convalescent. With secondary rise in temperature, the tonsils, which before 
had been only red, showed membranous patches, the exudation rapidly spreading until the 
entire pharynx was covered; throat symptoms very severe, with srreat swelling of cervical 
glands, but* the membrane did not extend beyond the pharynx. From sixth to twelfth day 
a most profound septicaemia, so that life was despaired of. The patient was a vigorous child, 
and, escaping both nephritis and pneumonia, made a good recovery. Convalescence quite 
rapid; no sequela?. Repeated cultures were made from the throat, but all showed only 
streptococci. Patient a girl four years old. Case observed in private practice. 



from laryngitis. If none of these complications develop, patients may 
withstand the toxic symptoms even when they are very severe. If the at- 
tack terminates in recovery, the local disease follows very much the same 
course as in diphtheria. The subsequent anaemia is, however, less severe, 
and none of the dangers of convalescence connected with cardiac or respi- 
ratory paralysis are present. 

There may be in connection with the local process in the throat, deep 
sloughing of the tonsils or adjacent structures, suppuration of the lym- 



1006 THE SPECIFIC INFECTIOUS DISEASES. 

phatic glands or in the cellular tissue of the neck, occasionally followed by 
serious haemorrhage. However, all these complications are rare, and if the 
patient survives the danger of the acute stage of the disease, he usually 
recovers. 

Diagnosis. — The clinical features which distinguish pseudo-diphtheria 
from true diphtheria have already been considered (page 974). It is im- 
possible in any case to be certain of the diagnosis except by cultures ; for, 
although by clinical symptoms alone one may in the great majority of 
cases be certain that a given case is one of true diphtheria, to say that any 
membranous inflammation of the throat is not diphtheria is impossible. 
The bacteriologists have taught us to be cautious in pronouncing too 
positively upon even the mild cases, as it has been clearly shown that 
some of them may be caused by the most virulent of diphtheria bacilli 
(page 965). 

In the secondary cases the diagnosis by clinical symptoms is more 
accurate. A membrane which appears in the throat early in the course 
of measles or scarlet fever, or at the height of the primary disease, is due 
to the streptococcus in at least four cases out of five ; while one which 
develops late or after the primary fever has subsided, is generally due to 
the diphtheria bacillus. 

Prognosis. — There is no more striking contrast between true and 
pseudo-diphtheria than in their mortality when they are seen side by side. 
Of 117 primary cases of pseudo-diphtheria observed by Park in the Willard 
Parker Hospital, New York, the mortality was 3*5 per cent ; of 127 cases of 
true diphtheria seen in the same institution at the same time, the mortality 
was 34*5 per cent. In a group of 154 hospital cases reported by Baginsky, 
there were 118 of true diphtheria, with a mortality of 38*2 per cent, and 
34 cases of primary pseudo-diphtheria, with a mortality of 5*5 per cent. 
From the same hospital, Philip has published a report upon 376 cases : 
332 of these were true diphtheria, with a mortality of 37 per cent ; 31 were 
cases of primary pseudo-diphtheria, with no mortality. The Bulletin of 
the New York Health Department contains a report upon 324 cases of 
pseudo-diphtheria in children, with a mortality of 9, or 2'8 per cent; 4 of 
the fatal cases complicated scarlet fever ; of the primary cases, the mor- 
tality was but 1-5 per cent. These were not hospital cases. The larynx 
is very seldom involved in primary cases, and unless this occurs, they 
nearly always recover. From the above data the deduction seems war- 
ranted that in a child previously healthy, primary pseudo-diphtheria is 
not a serious disease. 

Turning now to the secondary cases, we find a. very different state of 
things. Large statistics are not yet available, but from those already 
published it would appear that the usual mortality of pseudo-diphtheria, 
when it is secondary to scarlet fever and measles, is from 20 to 40 per cent. 
However, when these diseases prevail epidemically in institutions for 



PSEUDO-DIPHTHERIA. 1007 

young children, the mortality not infrequently reaches 70 or 80 per cent. 
Under such conditions the cases complicating measles give, as a rule, a 
higher mortality than those complicating scarlet fever. 

Prophylaxis. — In primary cases strict quarantine is unnecessary after 
the question of diagnosis has been settled. However, in private practice, 
healthy children should be excluded from the sick-room during acute 
symptoms. Cases of pseudo-diphtheria occurring in measles or scarlet 
fever should certainly be separated from uncomplicated cases. By way of 
prevention, something can be done in these diseases by keeping both nose 
and throat as clean as possible during every severe attack, by the use of 
an antiseptic mouth- wash or gargle, and by a nasal spray or even nasal 
syringing. For young children only weak solutions should be employed, 
such as a diluted DobelPs or Seller's solution, 1 : 10,000 bichloride, or a one- 
per-cent solution of boric acid. For those who are older, stronger solutions 
may be used, especially as a gargle. 

Treatment. — Every child with a membranous patch on its throat re- 
quires close watching. If the child is young — i. e., under ten years old — 
the diphtheria antitoxine should be administered, pending the result of 
a bacteriological examination. The primary cases require only the treat- 
ment of attack of tonsillitis ; the child should be put to bed, the bowels 
freely opened, and the diet should be light and fluid. If old enough 
he should gargle five or six times a day with some one of the solutions 
mentioned above ; but with younger children it is not worth while to per- 
sist in any attempts at local treatment, unless the case is manifestly pro- 
gressing unfavourably, when the treatment should be the same as in the 
secondary cases. 

The occurrence of a patch upon the tonsil of a child with scarlet fever 
or measles should be the signal for beginning active local treatment. If the 
child is old enough so that it can be done without force, the tonsils should 
be touched three times a day with a solution of bichloride, 1 : 500, with a 
swab, and a gargle should be used every hour during the day, of 1 : 5,000 
bichloride, or a saturated solution of boric acid. If there is a nasal dis- 
charge, the nose should be syringed with a bland solution, as in true diph- 
theria (page 987). In a younger child forcible swabbing is a very doubt- 
ful expedient. It is usually better to content one's self with syringing 
both the nose and the mouth with bland solutions. The frequency with 
which these measures are used will depend upon the severity of the case. 
The treatment of these cases by the " streptococcus antitoxine " has not 
yet reached a point where it is to be recommended. 

In the general management of these cases, feeding, stimulants, etc., the 
same plan is to be followed as in diphtheria. 






1008 THE SPECIFIC INFECTIOUS DISEASES. 



CHAPTEE IX. 

TYPHOID FEVER. • 

Typhoid feyer is an acute infectious disease due to a specific germ — 
Eberth's bacillus — which is abundantly present in the intestinal discharges 
of affected persons. It is very rare in infancy, but is not infrequent in 
childhood. As compared with the same disease in adults, the typhoid 
of childhood is characterized by its shorter duration, milder course, the 
infrequency of serious complications, and its low mortality. 

Etiology. — Age. — I have never seen typhoid fever in a child under 
two years old, and I believe it to be very rare, although, undoubted cases 
have been reported even during the first year. Murchison records one only 
six months old, and Ogle another four and a half months old, the diag- 
nosis being confirmed by autopsy in both instances. ~No case of typhoid 
was seen in the New York Infant Asylum during my eight years' service 
there, about ten thousand cases of illness having been treated during the 
period, and over seven hundred autopsies made. In seven years but one 
case was admitted to the Babies' Hospital, this being in a child over two 
years old. In over two thousand autopsies — chiefly upon children under 
two years old — made at the New York Foundling Asylum, Northrup did 
not meet with a single case of typhoid, nor was one known to have oc- 
curred in that institution for twenty years. The exceptional cases in 
infancy have almost invariably been observed in general epidemics. In 
an epidemic in Montclair, N. J., in 1894, 115 persons were attacked, 3 
of these being under two years old. In a severe epidemic in Stamford, 
Conn., in 1895, 406 persons were attacked, 4 being children under two 
years old. 

After the second year typhoid is by no ' means rare, but it is not until 
after the fifth year that it can be said to occur frequently. The following 
figures, embracing groups of cases reported by eight writers, represent 
perhaps as well as statistics can the relative frequency with which the 
disease is seen at the different ages : Of 970 cases, 8 per cent occurred 
under five years, 42 per cent between five and ten years, and 50 per cent 
between ten and fifteen years. 

Typhoid is almost invariably contracted by drinking water or milk 
which contains the germs of the disease. It is not within the scope of 
this article to discuss the manifold ways in which this may occur. 
The epidemics of Montclair and Stamford, already referred to, were 
definitely traced to infected milk. The infrequency of typhoid in in- 
fants is explained, in part at least, by the fact that most of the water 
and a large part of the milk taken have previously been boiled, or at 



TYPHOID FEVER. 1009 

least heated. In cases where the period of incubation could be deter- 
mined with something approaching accuracy, this has varied between five 
days and three weeks. 

Lesions. — Typhoid in young children is so seldom fatal that oppor- 
tunities for a study of the lesions have been limited. In a general way the 
lesions resemble those of adults except in severity. There is acute 
swelling of Peyer's patches, especially in the lower ileum, and of the soli- 
tary follicles of the small intestine and the colon, which may be followed 
by ulceration. There are frequently present the evidences of a mild catar- 
rhal enteritis. The mesenteric glands are swollen and the spleen is enlarged 
and soft. 

The intestinal lesions are, as a rule, much less severe than in adults ; 
in a considerable number of the cases this process does not go on to ulcera- 
tion ; and when ulcers form they are seldom large or deep, and perforation 
is very rare. Montmollin gives the following facts concerning 23 autop- 
sies, most of them, however, being in children over eight years old : ulcers 
were present in 17 cases ; they were situated in the lower ileum in 16, 
and in 10 they were only there ; in the ascending colon in 9, and only 
there in one case ; in one other case they were in the transverse colon, 
and in another they extended to the sigmoid flexure ; perforation oc- 
curred in 3 cases, in every instance in the lower ileum. In 25 autopsies 
by Reimer, ulcers were noted in 20, and in 2 there was perforation. The 
autopsies made upon young children show even less severe intestinal lesions 
than those mentioned. In fact, some cases in which the clinical diagnosis 
was beyond question, have shown only moderate redness and swelling of 
Peyer's patches, the solitary follicles and the mesenteric lymph nodes, — 
lesions which are exceedingly frequent in cases of simple diarrhoea, 
as my own experience has abundantly demonstrated. It should be empha- 
sized that in a doubtful case such post-mortem findings do not establish 
the diagnosis of typhoid. Indeed, they prove nothing unless cultures 
from the intestinal contents, the mesenteric glands, or other organs, show 
the typhoid bacillus. From a consideration of the clinical course of the 
disease, it seems very probable that in a large proportion of the cases which 
recover, ulceration does not take place. Enlargement of the spleen is prac- 
tically constant. The degenerative changes in the heart, the kidneys, and 
the liver are much less frequent and generally less severe than in adults. 
The lesions of other organs will be considered under Complications. 

Symptoms. — The peculiar features of typhoid in early life are seen only 
in children under ten years old; for after this time the disease does not 
differ essentially from the adult type. In brief, the typhoid of early child- 
hood may be characterized as a fever more often with nervous symptoms, 
than with intestinal symptoms. 

Onset. — A sudden onset with well-marked symptoms — fever, prostration, 
vomiting, etc. — is not uncommon ; in fact, it is quite as frequently seen as 
74 



1010 THE SPECIFIC INFECTIOUS DISEASES. 

the insidious beginning with lassitude, headache, coated tongue, anorexia, 
and gradual rise in temperature. In cases developing abruptly it often 
appears as if an acute indigestion had been the means of precipitating the 
attack. The most frequent initial symptom is vomiting ; a chill is rare. 
I have once known the disease to be ushered in by convulsions, but this 
is very exceptional. Epistaxis occurs as an early symptom rather less fre- 
quently than in adults. 

Condition of the boivels. — There is no constant relation between the 
severity of the intestinal lesions and the condition of the bowels. Taking 
large groups of cases together, diarrhoea is present in about half the num- 
ber. Morse's * observations, however, upon children under ten years old 
showed that constipation was present in two thirds, and diarrhoea in only 
one third of the cases. The diarrhoea is rarely profuse, from two to four 
discharges a day being the average. The appearance of the stools is sel- 
dom characteristic ; they are usually thin and fluid, often containing mu- 
cus. Constipation may be present at the beginning only, or it may persist 
throughout the attack. Tympanites is generally moderate in degree, and 
is often entirely absent ; it usually accompanies constipation. Marked 
iliac tenderness and gurgling are infrequent. 

Spleen. — By the end of the first week this is almost invariably found 
to be enlarged to a sufficient degree to be recognised by palpation (page 
832), unless a satisfactory examination can not be made owing to the 
presence of tympanites or the extreme irritability of the childo Usually 
the spleen extends but an inch or an inch and a half below the ribs, but at 
times it may be three inches or more. Swelling of the spleen is an impor- 
tant symptom not only for diagnosis, but also for prognosis ; its persistence 
always indicates that the disease is not at an end^ even though the tem- 
perature has reached the normal, and a relapse should be expected. 

Eruption. — It is the experience of nearly all who have seen much of 
typhoid in children that the eruption is less constant, less abundant, and 
less characteristic than in adults. Of 670 cases in Morse's collection, it 
was noted in but 60 per cent. The typical eruption consists of small, 
scattered, rose-coloured spots, which appear chiefly or solely upon the 
abdomen at the beginning o'f the second week. They come in successive 
crops, each one of which generally lasts three days, the whole duration 
of the eruption being about a week. The eruption reappears in most 
cases in which relapses occur. 

Prostration, emaciation, etc. — As a rule the prostration is quite suffi- 
cient to keep a child in bed after the first few days. The general weak- 
ness after this time is in direct proportion to the height of the tempera- 



* Typhoid Fever in Childhood, with an Analysis of 284 Cases ; Boston Medical and 
Surgical Journal, February 27, 1890. In this article, to which I am indebted for many 
statistics, will be found quite a full bibliography of the subject. 



TYPHOID FEVER. 



1011 



ture. Loss of flesh is steady and usually marked ; and in a prolonged 
attack there is marked emaciation. 

Temperature. — In the cases with a gradual onset, the typical tempera- 
ture carve is one which rises steadily for from two to seven days, fluctuates 
within the limits of one to three degrees during the second week, and 
steadily declines during the third week, reaching the normal on the aver- 
age at the end of the third week. In cases with an abrupt onset, the tem- 
perature rises at once to from 102 -5° to 105° F., but subsequently may 
run the same course as in the first group. 

The following are the most important variations from the temperature 
curve of adults : The initial rise is much more frequently rapid ; during 
the second week the re- 
mittent character is less 
marked, this probably de- 
pending upon the fact that 
ulceration is less frequent 
and less extensive ; the aver- 
age duration is shorter. In 
young children the propor- 
tion of cases in which the 
fever lasts only from eight 
to fourteen days is quite 
large (Fig. 170). In Wol- 
berg's * 277 cases, the dura- 
tion of the fever was four- 
teen days, or less in 70 per 

cent of the cases, and eight days or less in 2-8 per cent. Of this series, 
60 per cent of the children were eight years old or under. In a series 
of 295 cases reported by Montmollin, most of which were in children 
over eight years old, the disease lasted over three weeks in 30 per cent. 
The same peculiarity is brought out by Morse's figures: not counting 
relapses, the average duration of 75 cases under ten years old was 19-3 
days ; of 202 cases from ten to fifteen years old, it was 226 days. After 
the age of ten years the type of the fever is much like that seen in 
adults. The maximum temperature in the mild cases is 103° or 104° F. ; 
in the severe ones it often reaches 105° or 106° F., but rarely goes 
above this point. The range is usually higher than in adult cases of 
the same severity. Typhoid is about the only disease where the tempera- 
ture runs higher in older than in younger children. At the beginning of 
convalescence a subnormal temperature is very frequent, and by many 
writers is considered to be the rule. A secondary rise is most frequently 
due to errors in diet, but may occur from the development of complica- 



DAY 

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Fig. 170.— Typhoid fever of short duration in a child 
thirteen months old. Spleen enlarged ; eruption typi- 
cal ; no diarrhoea and only moderate abdominal dis- 
tention. There were two other cases in the family, 
all being due to the same cause— infected milk. ( After 
Northrup.) 



* Jahrbuch fur Kinderheilkunde, lid. x\vii, S. 28. 



1012 



THE SPECIFIC INFECTIOUS DISEASES. 



tions. A sudden fall indicates either perforation or intestinal haemor- 
rhage. 

Relapses are not infrequent ; they were present in 11 per cent of 284 
cases reported by Morse, and in 8*4 per cent of 533 cases collected by him. 
They follow about the same course as in adults. The interval between the 
attacks varies from two days to two weeks. The relapse is usually shorter 
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Fig. 171.— Typhoid fever with relapse. Child two and a half years old ; early temperature high 
and symptoms typical ; natural fall on fourteenth, day ; rise on seventeenth day apparently 
due to otitis; relapse on twenty-fourth day, with fresh eruption and return of splenic swell- 
ing which had disappeared. Temperature was subnormal at the end both of primary and 
secondary fever. 

Nervous symptoms. — As a rule, these are more prominent in severe 
cases than the intestinal symptoms, and are directly proportionate to the 
height of the temperature. The extreme nervous symptoms belonging to 
the typhoid state in adults — subsultus tendinum, carphologia, and coma 
vigil, with the dry glazed tongue, etc. — are rare" in childhood, and when 
present are generally in patients over ten years old. Headache and mild 
delirium at night are very frequent, the former being seen in the majority 
of cases. Young children are usually dull, apathetic, and often in a state 
of semi-stupor. Occasionally the disease may closely simulate meningitis. 
There may be general hyperassthesia, delirium or stupor, opisthotonus, 
contracted or unequal pupils and strabismus; but very seldom convul- 
sions. The nervous symptoms are usually most severe in the second, or 
early in the third week, and subside as the temperature declines. 

Pulse. — This is increased in frequency, but not to the degree that 
is seen in most diseases of childhood with a similar elevation of tempera- 
ture. The force and rhythm of the pulse are usually good, irregularity, 
very low tension, and dicrotism being rare as compared with adults; they 
may occur either at the height of the disease or during convalescence. 
Functional heart murmurs are quite frequent. 

Intestinal Immorrliage. — Of 94G collected cases, mainly from hospital 
reports, intestinal haemorrhage occurred in 30, or about three per cent ; 
the majority of these were in children over ten }^ears old. Thus Morse 
reports that in 77 cases under ten years old there was no case of haemor- 



TYPHOID FEVER. 1013 

rhage ; while in 204 cases between ten and fifteen years it was seen in 9 
cases. The most frequent time of its occurrence is toward the end of the 
second week. Montmollin reports 14 cases of haemorrhage, with 4 deaths ; 
in Morse's 9 cases there were 5 deaths. 

Intestinal perforation. — This is even more rare than haemorrhage. In 
1,028 collected cases, this accident occurred but twelve times, or in 1*1 
per cent. Eight of these proved fatal. Perforation is indicated by a sud- 
den fall in the temperature, with collapse ; usually there is vomiting and 
the rapid development of tympanites. The infrequency of both perfora- 
tion and haemorrhage is explained by the superficial character of the in- 
testinal lesions and the absence of deep ulceration. 

Complications and Sequelae. — The complications of typhoid in early 
life are infrequent and usually mild. Bronchitis is present in most of the 
severe cases. Pneumonia was noted in 9 per cent of seven hundred 
cases, reported by various authors. Both serous and purulent effusions 
into the chest are occasionally seen, and less frequently abscess of the lung. 
Gangrene of the lung, and severe inflammation or ulceration of the larynx 
are extremely rare. 

A small amount of albumin is found in the urine in most of the severe 
cases at the height of the disease, but a marked degree of nephritis is in- 
frequent. It was seen but three times in 295 cases reported by Mont- 
mollin. 

Complications referable to the nervous system are not very frequent, 
but are of much interest. Meningitis is extremely rare. Morse has col- 
lected twenty-one cases of aphasia, in two of which it was clearly due to 
embolism ; in the remainder, however, it apparently was not dependent 
upon any organic lesion. In two thirds of the cases it came on during 
convalescence, and in nearly all complete recovery occurred after an aver- 
age duration of three weeks. Aphasia usually followed a severe type of 
the disease, and in most of the cases was not accompanied by any other 
paralysis or by mental disturbance. Insanity is a rare sequel of typhoid in 
children, the usual type being acute mania. Adams (Washington) has 
recently reported two examples of this, both terminating in recovery. 
Chorea is not an infrequent sequel, and is seen rather oftener than after 
the other infectious diseases. In most of the series of reported cases no 
mention is made of multiple neuritis as a sequel of typhoid, but it is cer- 
tainly not very rare. 

Otitis is not an infrequent complication, occurring much oftener than 
in adults. It is principally seen in young children and during the cold 
season. Among the less frequent complications may be mentioned : paro- 
titis, which is usually suppurative and is seen in septic cases; abscess of 
the liver, examples of which have been reported by Bokai, Asch, and 
others; gangrenous inflammation of the mouth or genitals; pericarditis, 
endocarditis, and peritonitis, suppurative inflammations of joints, mul- 



1014: THE SPECIFIC INFECTIOUS DISEASES. 

tiple abscesses and furunculosis. Tuberculosis of the lungs or bones not 
infrequently follows typhoid. 

Diagnosis. — The diagnostic symptoms of typhoid are the continuous 
fever, the eruption, tympanites, and enlargement of the spleen. Unless 
the first two are present the case must be regarded as doubtful. One 
should be very slow to make the diagnosis of typhoid in a child under 
three years old, unless the disease is epidemic. The great proportion of 
sporadic cases reported as occurring in infancy are probably not typhoid. 
After the fifth year the disease is more frequent, and its symptoms in 
general resemble those of adults, except in severity. 

The differential diagnosis is to be made from malarial fever, ileo-colitis, 
meningitis, tuberculosis, and from other ill-defined continuous fevers of 
unknown origin. From malarial fever the diagnosis is to be made by the 
temperature curve, the plasmodium in the blood, and the effect of quinine. 
In most of the cases of malaria the temperature will be found to touch 
the normal at some time in the twenty-four hours. While the presence of 
the plasmodium in the blood is conclusive, its absence is not so. The 
administration of full doses of quinine is a diagnostic test of much prac- 
tical importance ; an irregular or remittent fever which yields promptly 
to quinine is most certainly not typhoid. 

Ileo-colitis and typhoid fever are not often confounded. The former 
is almost limited to the first three years of life, a time when typhoid is ex- 
tremely rare. The intestinal symptoms of ileo-colitis are marked even 
though the temperature is not high, and they are altogether more severe 
than is usual in typhoid. Enlargement of the -spleen, tympanites, and the 
eruption are not present in ileo-colitis, and without these the diagnosis of 
typhoid is very hazardous. 

The cerebral symptoms of typhoid may be difficult to distinguish from 
meningitis, unless one has watched their development. Irregular respira- 
tion, a slow, irregular pulse, localized paralysis and complete coma are 
seldom if ever seen in typhoid, and a retracted abdomen very rarely, while 
the enlarged spleen and the peculiar eruption are not seen in meningitis. 
Constipation is seldom so marked in typhoid as in meningitis. Further- 
more, in typhoid with pronounced nervous symptoms, the temperature is 
usually higher than in meningitis. General tuberculosis and typhoid not 
infrequently resemble each other so closely that for a week or even two 
weeks a differential diagnosis is impossible. Until local evidences of 
tuberculosis appear, usually in the lungs, the two conditions can not be 
positively distinguished. (See chapter on Tuberculosis, page 1036.) 

There are not infrequently seen in infancy and in early childhood 
cases of indeterminate fever which last from one to two weeks and gradu- 
ally subside, terminating in recovery, but not influenced by quinine, and 
in which- the plasmodium is not present in the blood. Many writers are 
inclined to regard these cases as typhoid. However, without enlargement 



TYPHOID FEVER. 1015 

of the spleen, the eruption, and tympanites, the diagnosis of typhoid is to 
my mind extremely doubtful. 

Prognosis. — Of 2,623 cases collected from the reports of twelve differ- 
ent writers, the mortality was 5*4 per cent. These are, however, almost 
all taken from hospital reports, where as a rule the mildest cases are not 
brought for treatment. The mortality of the disease in children, includ- 
ing all cases, probably does not exceed 3 or 4 per cent. Death seldom 
occurs from the disease itself, but usually from some accident or compli- 
cation ; the most frequent causes of death are pneumonia and intestinal 
haemorrhage or perforation. Occasionally death results from general sep- 
sis with parotitis, bed sores, nephritis, meningitis, or heart paralysis. The 
most fatal period is the third week. 

Treatment. — The low mortality of this disease shows how successful all 
methods of treatment are likely to be considered. In the great majority 
of cases very little active treatment is required. Every patient with ty- 
phoid should be put to bed and kept there during the febrile period, and 
a few days beyond it, no matter how mild the attack may be. A fluid diet 
also should be prescribed in every case, preferably milk which should be 
given regularly every three hours, and not pushed greatly beyond the de- 
sires of the patient. Milk may be diluted or partially peptonized, and 
kumyss or matzoon may be substituted for it if the stomach is irritable. 
Plenty of water should be allowed, unless it disturbs the stomach. 

The discharges should be immediately and thoroughly disinfected by 
a solution of carbolic 1 : 20. If the movements are in a chamber or a 
bed-pan they should be covered with this solution for at least six hours 
before they are thrown into the water closet. If napkins or diapers are 
used, they should be soaked in some efficient antiseptic solution for 
twelve hours and then thoroughly boiled. Sheets stained by discharges 
should be treated in the same way, and all bed-linen should be boiled 
for two hours apart from the washing of the family. Aside from 
these general measures the treatment of the disease is the treatment of 
symptoms. 

Diarrhoea calls for treatment only when the movements exceed four or 
five in twenty-four hours. If no more than this number are present, they 
should not be interfered with. Opium and bismuth are undoubtedly the 
best means for controlling excessive diarrhoea, but care should be taken 
that they are not pushed to the degree of inducing constipation. 

Constipation may be relieved by small doses of the salines, or an occa- 
sional dose of castor oil, but all active purgation should be avoided. In 
many cases daily irrigation of the colon with tepid water is better than 
anything else. On the whole, constipation is more troublesome to con- 
trol than diarrhoea. 

Tympanites is rarely severe enough to require treatment; it may be 
relieved by turpentine stupes, by a glycerin suppository, or a small glycerin 



1016 THE SPECIFIC INFECTIOUS DISEASES. 

injection (one teaspoonful of glycerin to two ounces water), or, better still, 
by the use of the rectal tube. 

Whenever the temperature goes above 103° F., antipyretic measures 
are indicated. In mild cases, sponging with cold water or with alcohol 
and tepid water, equal parts, is generally sufficient. In cases which do 
not yield to such measures baths should be employed. For young chil- 
dren the graduated bath (page 48) should be used ; for those who are 
older the bath should be from 75° to 85° F., its duration depending upon 
the amount of reduction affected. The body should be actively rubbed 
during the bath to prevent shock and cardiac depression. The only contra- 
indications to the bath are extreme prostration with great cardiac weak- 
ness, or the existence of intestinal haemorrhage. The ease with which the 
cold bath can be employed in children makes it especially valuable. The 
cold pack (pages 47 and 48) may be substituted for the bath where circum- 
stances make the latter impracticable. The bath or pack should be repeated 
in an average case in from two to four hours, or whenever the temperature 
has risen to 103° F. The method of applying cold which causes the least 
disturbance to the patient is the one which should always be selected. 

The milder nervous symptoms — headache, restlessness, sleeplessness, 
etc. — may be relieved by an occasional dose of phenacetine, either alone or 
in combination with the bromides, or by cold or tepid sponging ; the 
more severe ones usually occur with high temperature, and are best con- 
trolled by the cold bath. 

Stimulants in most of the cases are not called for. They are to be 
given according to the indications afforded by the pulse, the first sound 
of the heart, and the child's general condition. They are seldom needed 
earlier than the middle of the second week ; they should be well diluted. 
Brandy or whisky is to be preferred to wines, and, unlike the milk, they 
may be given at frequent intervals whenever the patient will take them 
best. Intestinal haemorrhage calls for absolute quiet, morphine hypoder- 
mically, and turpentine or ergotine by the mouth. Intestinal perforation 
is to be treated by hypodermics of morphine. 



CHAPTER X. 
TUBERCULOSIS. 

Tuberculosis is an infectious communicable disease, now universally 
admitted to be due to the bacillus tuberculosis of Koch. It may be local 
or general, and may involve any organ and almost any structure in the 
body. 

Etiology. — Frequency. — Miiller, in 500 autopsies upon children in 
Munich, found tuberculosis in 40 per cent of the cases ; in 30 per cent 



TUBERCULOSIS. 1017 

death was due to tuberculosis, and in the remaining 10 per cent tubercu- 
losis was found at autopsy in patients dying from other diseases. I do not 
think it is so frequent in this country, for, of 726 consecutive autopsies in 
the New York Infant Asylum, tuberculosis was found in only 58, or 8 per 
cent of the cases ; 6 per cent of the deaths were due to tuberculosis, and in 
2 per cent the children died from other diseases. Of 319 consecutive autop- 
sies in the Babies' Hospital, tuberculosis was found in 44, or 14 per cent. 

Predisposing causes. — The predisposition to tuberculosis is general or 
local. General predisposition may be inherited directly from parents who 
have themselves suffered from tuberculosis, or from those who, in conse- 
quence of syphilis, alcoholism, or any other constitutional vice, have trans- 
mitted a feeble constitution to their children. Inherited predisposition is 
exceedingly common, and really signifies a diminished resistance of the 
cells of the body to tuberculous infection. It should be distinguished 
from the very exceptional condition of congenital tuberculosis, where in- 
fection takes place before birth. General predisposition includes the 
child's surroundings, in so far as they affect tbe constitution and lower 
the general vitality. Children reared in the city, either in institutions 
or in crowded tenements, are more frequently affected than those who 
have had the advantage of the best surroundings, not only because of their 
increased chances of exposure, but also from their feebler resistance. 
Marasmus, intestinal diseases, and, in fact, any debilitating general or 
local disease, may predispose to tuberculosis. 

A local predisposition is created by any pathological condition of the 
mucous membranes or organs most exposed to infection. The most im- 
portant are repeated attacks of bronchitis, broncho-pneumonia, or pleurisy, 
and chronic catarrhal inflammation of the mucous membrane of the nose or 
pharynx, so frequently associated with enlarged tonsils or adenoid growths 
of the pharynx. Much less frequently the local predisposition is the result 
of some previous disease of the intestines. 

The role played by other diseases in the development of tuberculosis is 
an important one, and until recently but little understood. In a very 
large number of cases tuberculosis develops as a sequel of one of the 
acute infectious diseases, particularly measles, pertussis, or epidemic in- 
fluenza. In such cases there has probably existed previously a latent tuber- 
culosis, usually in the bronchial lymph nodes. This process, sometimes 
long quiescent, under the stimulus of a new infection may be awakened to 
activity. It is to be noted that it is the infectious diseases that are in- 
timately associated with pulmonary complications, which are liable to be 
followed by tuberculosis. 

Age. — No age is exempt from tuberculosis. It was formerly believed 
that the disease was rare in infancy, but recent observations have shown 
that, although its form is somewhat different, it is more frequent in in- 
fancy than at any period of later childhood. Statistics, taken chiefly from 



1018 THE SPECIFIC INFECTIOUS DISEASES. 

two institutions where children np to four years of age are received, give 
the following results, the diagnosis being confirmed by autopsy in nearly 
every case under two years old : 

Under three months 5 cases 

From three to six months 21 " 

" six to twelve months 31 " 

" twelve to eighteen months 29 " 

" eighteen to twenty-four months 10 " 

*' two years to five years 32 " 

Over five years 15 " 

Total 143 " 

It will be seen that the first year furnished 57 cases, the second year 
39, and the succeeding three years but 32 cases. 

Mode of infection. — The possibility of intra-uterine infection, or the 
direct transmission of tuberculosis, has been demonstrated by cases re- 
corded by Birch-Hirschfeld,* Lehmann, Bar and Kenon and others. In 
the case first referred to, the organs of a foetus, taken from a woman dying 
from general tuberculosis, were found to contain tubercle bacilli, although 
no tuberculous lesions were present ; bacilli were found in the capillaries 
of the liver ; inoculations from the spleen and kidney produced the dis- 
ease in animals ; and the placental tufts were filled with bacilli. In Leh- 
mann's case there were tuberculous lesions in the placenta as well as in 
the child's organs. 

Intra-uterine infection is highly probable in many of the cases of chil- 
dren born of tuberculous mothers, who develop the disease during the 
first few months of life, although they may show no evidence of it at 
birth. Among my own cases there were five which died of tuberculosis 
during the first three months. One of these children was but twenty 
days old. It was born prematurely of a mother who at the time w r as suf- 
fering from advanced tuberculosis, and died from that disease shortly 
after the child. Besides other lesions, the autopsy showed, in the case of 
the mother, tuberculosis of the endometrium. In this instance the infec- 
tion of the child certainly took place before birth. 

In another case, a child died of general tuberculosis, with wide-spread 
lesions, at the age of seven weeks. The mother of this infant died from 
tuberculosis eleven days after the birth of the child. Intra-uterine infec- 
tion must, however, be considered rare in comparison with the frequency 
with which infection takes place after birth, instead of being, as was 
formerly supposed, very common. 

Tuberculosis may be communicated by direct inoculation, as in the 
case of a bite from a person suffering from the disease, several instances 
of which are on record. The rite of circumcision performed by a rabbi 

* Wiener medicinische Blatter, No. 17, 1891. 



TUBERCULOSIS. 1019 

suffering from tuberculosis is also known to have caused the disease. One 
of the most striking instances of direct infection is that reported by 
Reich.* In a town of about 1,300 inhabitants, the obstetric practice was 
divided between two mid wives. Within fourteen months no less than 
ten infants, who had been delivered by one of these women, died of tuber- 
culous meningitis. In none of these families was there a history of tuber- 
culosis. This midwife was found to be suffering from pulmonary tuber- 
culosis, and died from that disease. It was her custom to remove the 
mucus from the mouth of the newly-born infants by direct mouth-to- 
mouth aspiration, and then to establish respiration by blowing into the 
nose. In the practice of the other midwife, who was healthy, no cases of 
tuberculosis occurred, although she treated the newly-born infants in the 
same fashion. 

The following instance of infection has recently come to my notice : 
Two little girls were much in the room and about the bed of a young 
woman who was suffering, it was afterward discovered, from pulmonary 
tuberculosis. Within three months of that time, and within six weeks of 
each other, both died of tuberculous meningitis. 

Examples might be multiplied indefinitely of cases where children 
have contracted the disease from a close exposure to nurses or other per- 
sons in the household. More frequently, however, the mode of infec- 
tion can not be traced, the exposure doubtless being in most of these 
cases long antecedent to the development of symptoms. 

Aside from accidental inoculation already mentioned, the tubercle 
bacilli may gain an entrance to the body either through the respiratory or 
the alimentary tract or the skin — the last, however, being so very rare that 
it need only be mentioned. In infancy and early childhood, infection 
through the respiratory tract is the rule. This is conclusively shown by the 
situation of the primary lesions (pages 361 and 1022). The source of the 
bacilli in the inspired air is mainly the sputum of patients suffering from 
pulmonary tuberculosis, which dries and becomes part of the dust of the 
street, of the railroad car, the home, or the hospital. Bacilli may be 
taken into the alimentary tract with milk from tuberculous cows or tu- 
berculous women. Both of these I believe to be very rare.f Unless 

* Berliner klinische Wochenschrift, No. 37, 1878. 

f In this connection the following incident is interesting as bearing upon the other 
side of the question : Near a large American city was a fancy stock farm of registered 
Jersey cows, which supplied milk for table use and infant feeding to a large number 
of families in the wealthiest part of the city, for a period of over ten years. At the 
end of that time the tuberculin test was used for the first time, and 45 per cent of 
these cows were found to be tuberculous, and were killed by order of the State Board 
of Health. The diagnosis was confirmed by autopsies upon the animals in every 
instance. An investigation was instituted among the children who had been fed 
upon this milk, but in only one case of many hundreds could it be learned that tuber- 
culosis had developed, and in this instance it was by no means established that the 



1020 THE SPECIFIC INFECTIOUS DISEASES. 

the udder is the seat of disease, the number of bacilli in cow's milk is so 
small that the chances of infecting a child after these bacilli have passed 
the stomach are exceedingly small. Its possibility even is questioned by 
many good authorities. The same may be said regarding the transmis- 
sion of tuberculosis through the milk of a nurse. Infection from the 
meat of tuberculous animals is doubtless a possibility, but hardly more. 
Bollinger's experiments in feeding animals with the expressed juice of 
such meat gave negative results. 

The Various Paths of Infection adopted by the Tubercle Bacillus. — 
The tubercle bacilli which enter the body with the inspired air are ar- 
rested upon the mucous membrane of the upper or the lower respiratory 
tract ; upon which one of these, is largely determined by local conditions 
in the various mucous membranes. Both clinical experience and animal 
experiments indicate that the bacilli may pass through a mucous mem- 
brane without inducing in it a tuberculous disease, but that penetration 
is much easier if the mucous membrane is the seat of a catarrhal inflam- 
mation, or if the epithelium has been injured. The bacilli are taken up 
by the lymphatics from the surface of the mucous membrane upon which 
they have lodged, and are carried to the nearest lymph nodes, where, 
for a considerable time at least, they are arrested. It has long been a 
familiar clinical fact that the great majority of children who suffer from 
tuberculosis of the cervical lymph nodes escape general tuberculous in- 
fection, so eminent an authority upon this subject as Treves considering 
this to be a very exceptional result. 

It is not infrequent, in autopsies both upon children and adults dying 
from various non-tuberculous diseases, to find tuberculosis limited to the 
bronchial lymph nodes. In a series of 125 autopsies at the New York 
Foundling Asylum upon children with tuberculosis, Northrup * found 
13 such cases, these being children who had died from acute non- 
tuberculous diseases. Many confirmatory reports have been published 
by Bollinger (Munich) and others. I have myself seen it in a number 
of instances. 

H. P. Loomis f (New York) made inoculation experiments with the 
bronchial lymph nodes taken from the bodies of thirty persons dying by 
violence or from acute disease, in whom no evidence of tuberculosis in any 
other part of the body could be found at autopsy. From eight of the cases 
he produced tuberculosis in animals by inoculation. Arnold has shown 

milk had been the source of infection. It should be stated that this was before the 
days of sterilizing milk for infant feeding. Besides the families who took the milk 
in the manner mentioned, the employees at the farm were accustomed to drink the 
skimmed milk in large quantities daily as a beverage in the place of water. Many of 
them continued to do this for years, and yet not one of them developed tuberculosis. 

* New York Medical Journal, February 21, 1891. 

f The Medical Record, December 20, 1890. 



TUBERCULOSIS. 1021 

by experiments with dust inhalation in animals, that in a short time the 
bronchial lymph nodes were rilled with dust, though the bronchi and 
alveoli were free ; but, however prolonged the inhalation, dust was never 
found in the lymphatic vessels beyond the nodes. 

Arriving at the lymph node, the bacilli light up a tuberculous inflam- 
mation of varying degrees of intensity, depending upon their number 
and upon local conditions. This inflammation may pass through the 
usual changes of tuberculous glands — congestion, swelling, cell prolifera- 
tion and caseation ; or the process may be arrested at any point, and the 
products of inflammation become encapsulated by a proliferation of fibrous 
tissue, in which condition they may remain latent in the body for an in- 
definite number of years — possibly for a lifetime. This is what occurs in 
older and more vigorous children, and it is consistent with every outward 
sign of health ; but it is a smouldering ember which at any time may be 
fanned into flame under the stimulus of an inflammation excited by some 
other cause. 

In infants and young children, the tendency is always for the bacilli to 
lodge first in the bronchial lymph nodes, probably on account of the 
favourable conditions for entrance existing in the bronchi and lungs. In 
those who are delicate and have but little resistance, the process in the 
lymph nodes is likely to go on to caseation and softening, and secondarily 
to this process in the glands, the lung becomes infected. Of 91 cases 
observed by Northrup, in which the mode of infection could be pretty 
accurately traced, in 88 it was primarily in the bronchial lymph nodes. 
The manner of the extension of the disease to the lung is not always easy 
to trace ; but in many instances it has been shown to be the result of 
the softening of one of these small tuberculous lymph nodes, which then 
ulcerates through the wall of one of the small bronchi or a blood-vessel, 
in this way distributing its bacilli through the lung. 

Although this is the course usually taken by bacilli when they are in- 
haled, it is not always the case. Lesions in the lungs are occasionally 
found where the lymph nodes are not involved ; and there are other cases 
in which advanced changes exist in the lung, while only the earlier ones 
are seen in the lymph nodes. In these cases, which perhaps are to be 
considered as exceptional, the tuberculous process probably begins in 
the walls of the small bronchi, the alveoli, or in the connective-tissue 
septa. 

Tubercle bacilli entering the alimentary tract rarely cause lesions of 
the gastric mucous membrane, or through it reach the lymphatic circula- 
tion. In the intestines, however, more favourable conditions exist. It is 
possible for the bacilli to reach the mesenteric lymph nodes without caus- 
ing disease of the intestinal mucous membrane, but I believe it to be ex- 
ceedingly rare ; for by careful search I have never yet failed to find in- 
testinal ulceration where the lymph nodes were manifestly tuberculous. 



1022 



THE SPECIFIC INFECTIOUS DISEASES. 



Lesions, — In the following table are given the different lesions of tu- 
berculosis as they were found in 119 autopsies, of which I have notes. 
These represent the lesions of infancy and early childhood, 66 per cent of 
these children being two years old or under. There are introduced for 
comparison, the statistics of 131 autopsies from the Pendlebury Hospital 
Keports (Manchester, England). Very few of the cases in this series were 
under three years, the hospital admitting only older children : 

Frequency of the Different Visceral Lesions of Tuberculosis. 



Organs. 



Lungs 

Pleura 

Bronchial lymph nodes. . 

Brain 

Liver 

Spleen 

Kidneys 

Stomach 

Intestines 

Mesenteric lymph nodes. 

Peritonaeum 

Pericardium 

Endocardium 

Thymus 

Suprarenal capsules 

Pancreas 



Personal cases ; 

119 autopsies (chiefly under 

three years). 



117 

69 

108 

40 

77 

88 

46 

5 

40 

38 

10 

7 

1 

3 

2 

3 



99 - oer cent. 

58-0 ^ " 

96-0 " 

37-0 

65-0 

75-0 " 

39-0 " 

4-0 " 

37-0 " 

35-0 " 

9-0 " 

6 " 

0-8 " 

2-5 " 

1-7 " 

2-5 . " 



Pendlebury Hospital Reports 

131 autopsies (chiefly over 

three years). 



122 

100 

91 

60 

86 

76 

54 

1 

65 

77 

37 

4 



93*0 per cent. 

76-0 " 

70-0 " 

46-0 " 
65-0 

58-0 " 
41-0 

0-8 " 

50-0 " 
59-0 

28-0 " 

3-0 " 



The varieties of tuberculosis seen at different ages. — During the first 
two years of life, tuberculosis, with great uniformity, involves first the 
bronchial lymph nodes and the lungs. It is most frequently the pul- 
monary process which is the cause of death, and next to the lungs, death is 
due to tuberculosis of the brain. It is rare for any other local tuberculous 
process to be fatal at this time of life. Of 72 cases of tuberculosis in the 
first two years of life, in which the exact nature of the lesions was deter- 
mined by autopsy, the lungs were extensively involved in all ; but death 
was due to meningitis in 13, in only one to tuberculous peritonitis, and in 
one to haemorrhage from a tuberculous ulcer of the intestine. During 
infancy, meningitis is rare except when associated with pulmonary tuber- 
culosis ; but after the second year, meningitis 'is relatively more frequent. 
Of the deaths from tuberculosis during the third year, meningitis was 
present in over one half the number. After this time it frequently exists 
with few and sometimes with no lesions in the lungs, it being often sec- 
ondary to tuberculosis of the bones or lymph nodes. 

Beginning with the third year, tuberculosis of the bones, cervical and 
mesenteric lymph nodes, peritoneum, and intestines, becomes more frequent, 
and in any of these organs it may occur as the principal lesion, although 
at autopsy the lungs, even at this age, are rarely found free from infection. 



TUBERCULOSIS. 1023 

Pulmonary Lesions. — As compared with adults, the pulmonary tuber- 
culosis of children is more widely diffused, and the predominance of cases 
in which the lesion is at the upper lobes, though less marked, still exists. 
The peculiarities are principally seen in children under two years. In 
those who have passed the sixth or seventh year, the pathological processes 
resemble those of adult life. In my own autopsies the oldest lesions were 
found 69 times in one of the upper lobes (left 35, right 34) ; 23 times in 
the right middle lobe, and 35 times in one or other of the lower lobes 
(left 24, right 11). Although localized tuberculous processes are frequently 
met with in patients dying from other diseases, those who die from tuber- 
culosis usually show wide-spread lesions of the lungs, and the younger the 
child the more diffuse they are. 

1. Miliary tuberculosis of the lungs. — In nearly every case of pulmo- 
nary tuberculosis, miliary tubercles are found in some part of the' lung; 
usually they are seen upon the surface and in scattered areas in the 
vicinity of some older process. Occasionally in older children, but 
very rarely in infants, they are distributed through nearly the whole of 
both lungs. 

In some places the lung, with the exception of these gray granulations, 
appears quite normal ; in others it is congested, and shows between the 
tubercles the lesions of simple broncho-pneumonia in its various 'stages. 
There is also an acute bronchitis of the middle-sized and smaller bronchi. 
The microscope shows that the tubercles usually develop in the walls of 
the small bronchi or the blood-vessels, or very close to these structures. 
In their gross appearance, the lungs in these cases resemble those in ordi- 
nary acute broncho-pneumonia, with the exception that everywhere upon 
the surface and throughout the substance of the lung are seen the small 
gray granulations, and in most cases some small yellow tuberculous nod- 
ules. The pleura is usually normal except for the presence of the tuber- 
cles. This form of the disease represents the rapid dissemination of 
tubercle bacilli throughout the lungs, the miliary tubercles being the 
result of the inflammation excited by their presence. 

2. Tuberculous broncho-pneumonia. — This is the most frequent and 
the most characteristic form of tuberculosis in infants and young chil- 
dren, and it is the one which at this age usually causes death. In this 
form of disease there are produced in the lung, caseous nodules, or larger 
caseous areas, some of which have usually undergone softening by the 
time the case comes to autopsy. The process generally runs a somewhat 
subacute course. With the lesions mentioned there are always associated 
those of simple broncho-pneumonia. 

The pleura is involved in almost every case. There may be simply 
dense connective-tissue adhesions which bind the lung firmly to the chest 
wall, or the pleura may be greatly thickened and contain caseous deposits. 
Occasionally empyema is seen, but it is almost always sacculated and small. 



1024 THE SPECIFIC INFECTIOUS DISEASES. 

Both lungs are usually involved, but one to a much greater degree than 
the other. There are found large areas of consolidation which some- 
times involve an entire lobe, but more often areas are seen in several lobes. 
These portions of the lung appear much firmer and harder than in ordi- 
nary pneumonia. The upper lobes are more often affected than the 
lower, and especially that part of the lobe which is near the root of the 
lung, on account of its frequent association with tuberculosis of the 
bronchial glands ; the disease very often extends forward from this point 
to the middle lobe of the right, or the corresponding part of the left lung. 
On section the affected part of the lung usually shows many caseous 
nodules varying in size from a pin's head to a walnut, which appear of a 
pale yellow colour, and resemble caseous lymph nodes. They contain giant 
cells and are usually filled with bacilli, those which have softened con- 
taining yellow pus. There is nearly always seen in some part of the 
lung, a large caseous area ; and not infrequently there may be diffuse 
caseation of almost an entire lobe (Fig. 172). Sometimes no spot of 
softening is seen even in these -large areas, but in the great majority 
of them there are found cavities of variable size with ragged but not 
dense walls. 

Softening and excavation represent the final stages of the process in 
tuberculous pneumonia. It has been shown by Prudden that these changes 
are chiefly or entirely due to other pathogenic organisms— usually the 
streptococcus or staphylococcus — and not to the tubercle bacillus. Soften- 
ing usually begins in the centre of a caseous part, often at several points 
at the same time. Areas of excavation large enough to deserve the name 
of cavities were present in thirty-five of seventy two autopsies upon tuber- 
culous patients, two years old and under. They are found in the great 
majority of the cases in which continuous pulmonary symptoms have been 
present till death. They vary in size from a cherry to a hen's egg, and 
sometimes a much larger one is seen (Fig. 173). They are usually rather 
deeply seated, and partially or entirely filled with caseous masses or pus, 
but very seldom perforate the pleura, causing pneumothorax or pyopneu- 
mothorax. It is rare in a young child to find cavities surrounded by dense 
fibrous walls such as are seen in older children or in adults; for in infancy 
the process of softening once begun usually advances steadily until the 
death of the patient. 

One of the most frequent conditions seen in autopsy is a small cavity 
surrounded by a larger area of caseous pneumonia, and this in turn sur- 
rounded by a zone of simple pneumonia through which are scattered 
many miliary tubercles. Often the lesions mentioned will be present in 
one lobe, while the other lobe or the opposite lung will show only the 
changes of a simple pneumonia. 

The bronchial lymph nodes are in these cases invariably found to be 
tuberculous, and not only those at the root of the lung, but if a dissection 



TUBERCULOSIS. 1025 

is made, a chain of these tuberculous glands will be found to follow the 
larger bronchi for some distance into the lung (Fig. 176). Sometimes 
one may discover one of these which has softened and ulcerated through 
into a small bronchus, and in this way has spread the infection through- 
out that part of the lung. 

Microscopical examination of these cheesy nodules shows that they 
most frequently begin as tuberculous deposits in the walls of the small 





Fig. 172. Fig. 173. 



Fig. 172.— Tuberculous pneumonia. A vertical section through the middle of the right lung 
of a child thirteen months old. The greater part of the upper lobe is uniformly caseous — a 
diffuse tuberculous pneumonia; near the centre the commencement of a cavity is seen; be- 
low it has the appearance of a consolidation from simple pneumonia. The part of the lower 
lobe shown is normal. 

Fig. 173. — Cavity from breaking down of tuberculous pneumonia; another view of the same 
lung, the section beincf made very near the posterior border of the lung. The cavity occu- 
pies at this point nearly the whole of the upper lobe. At autopsy this cavity contained nu- 
merous loose caseous masses, the largest being the size of a marble. The lower lobe is 
normal. (For history see Fig. 179.) 

bronchi, either in the mucous membrane, the fibrous coat, or the lymphat- 
ics ; sometimes, however, they begin in the walls of a small vein or artery. 
Cell proliferation takes place, separating the coats of the bronchus or 
blood-vessel, and partly or entirely obstructing its lumen. Softening may 

75 



1026 



THE SPECIFIC INFECTIOUS DISEASES. 



take place and the contents be discharged into the bronchus or blood- 
vessel. About this focus other changes of an inflammatory character 
















: .v\^-'i^ 






• ■'.-: m m*^\ 

.. ■'■.& •:■..'• :■•:•?■■ ...■■- •,'>'.'.•-'■'{< ■■ 







Fig. 174. — A small tuberculous noclule surrounded by lung tissue which shows only slight in- 
flammatory changes. The centre of the nodule is necrotic ; at its periphery is shown infil- 
tration with round cells and several giant cells. (From Karg and Schmorl.) 

occur, as a result of which each cheesy nodule is surrounded by a zone 
of simple broncho-pneumonia (Fig. 174) which tends, in a measure at 
least, to limit the tuberculous process. The larger caseous areas are 
formed by an extension of this process to the zone of pneumonia 
which surrounds it ; but in its further growth it is still preceded by 
a simple pneumonia (Fig. 175). The rapidity with which the lesions 
advance differs much in the different cases, and is greatly modified by 
the patient's age ; in infants the progress is apt to be continuous until 
the death of the patient; in older children it is usually slower, and is 
often interrupted by longer or shorter intervals of arrest and even of par- 
tial retrogression. Such periods are marked by the absorption of the sim- 
ple inflammatory products in the zone of pneumonia surrounding the 
tuberculous nodule, accompanied by improvement in the symptoms and 



TUBERCULOSIS. 



1027 



often by a disappearance of some of the physical signs. During these times 
of quiescence there is an opportunity for the organization of the cells in- 
filtrating the alveolar walls and septa into a more or less resistant fibrous 
wall which acts as a barrier against the advance of the pathological pro- 
cess. 

Not infrequently one sees in the post-mortem room one or two caseous, 
or less frequently calcareous, nodules encapsulated by firm, organized con- 
nective tissue where a most careful search fails to show any other tubercu- 




£ 



SL_ - A 



Fig. 175. — Pulmonary tuberculosis, showing areas of tuberculous pneumonia and conglomerate 
tubercles. In the greater part of the specimen the air vesicles are filled with the products 
of simple pneumonia. The larger dark areas, A A A, are spots of tuberculous pneumonia. 
while at B B only single air vesicles or groups of two or three are affected by the tuber- 
culous process. The specimen shows a comparatively early stage of the process, of which 
the late stage is represented by Fig. 172. Patient, a child three months old; the symptoms, 
those of simple acute pneumonia. There were conglomerate tubercles scattered through 
both lungs, and large areas of cheesy pneumonia in the left lower lobe. 



lous lesion in the lung. If, however, the nodules are widely scattered 
through the lung, such an arrest of the process is not to be expected. 
3. Chronic pulmonary tuberculosis, chronic phthisis. — With the patho- 



1028 ™E SPECIFIC INFECTIOUS DISEASES. 

logical process as it is seen in adults, we have nothing to do in infants 
and very young children. In those who have reached the age of eight 
or ten years the disease is essentially the same as in adult life, and need 
not be described here. 

In little children the nearest approach to this condition is seen in the 
cases of tuberculous broncho-pneumonia, which run a slow, irregular, 
and somewhat chronic course. The essential features of the process in 
these patients is a chronic interstitial broncho-pneumonia with tubercu- 
lous nodules which rarely undergo softening, but usually become encap- 
sulated. 

The gross lesions closely resemble those of simple chronic broncho- 
pneumonia (page 535). There are the same generalized pleuritic adhe- 
sions and the shrunken cicatricial condition of the part of the lung most 
affected, with bronchiectasis, compensatory emphysema, etc. The tuber- 
culous nodules are old and for the most part converted into dense fibrous 
tissue in the centre of which, however, some softened, caseous areas are 
often seen. Lesions like those described, which may be regarded as a 
form of recovery, are usually found in patients who have died of other 
diseases ; sometimes in those who have died of other forms of tuberculosis 
— of the brain, bones, or peritonaeum ; at other times they are associated 
with a recent process in some other part of the lung. The bronchial 
glands may be somewhat enlarged and contain encapsulated caseous 
masses, or they may be calcareous. 

Bronchial lymph nodes {bronchial glands). — The prominence of the 
lesions of the lymph nodes is one of the most striking features of tuber- 
culosis in infancy and early childhood. Those Avhich are most frequently 
affected are connected with the bronchi. The lymph nodes, to which the 
term " bronchial glands " is generally applied, consist of three groups : 
the first of which surround the trachea ; the second are situated at the 
bifurcation of the trachea and surround the primary bronchi ; while the 
third follow the course of the bronchi into the lung, being found, accord- 
ing to anatomists, as far as the fourth division. The anatomical relation 
of the different groups should be borne in mind, since upon them the 
symptoms principally depend. The first group, or the peri- tracheal lymph 
nodes, are in relation with the superior vena cava, the pulmonary artery, 
the pneumogastric and recurrent laryngeal nerves : the second group, at 
the bifurcation of the trachea, with the oesophagus, pneumogastric nerve, 
and aorta; the third group, with the bronchi and the branches of the 
bronchial and pulmonary arteries and veins. 

All the groups are usually involved at the same time, but in varying 
degrees, and in most cases those belonging to one lung to a greater extent 
than the other ; in my own cases those of the right side have more often 
been involved than those of the left. There may be simply two or three 
tumours as large as a hazelnut, or there may be a mass two or three inches 



PLATE XIX. 




Tuberculosis of the Tracheo-Bronchial Lymph Nodes. 

From a fairly nourished child, four months old, who was under observation for 
three weeks, with slight fever and a most severe, teasing, dry cough, which was almost 
constant, and upon which no treatment seemed to have the slightest effect. At first 
there were no signs of disease in the lungs ; later there were a few coarse scattered 
rales. 

There were small tuberculous deposits throughout both lungs, with quite a large 
area of cheesy pneumonia in the right middle lobe, and scattered miliary tubercles in 
other organs. 



TUBERCULOSIS. 



1029 



in diameter, which is made up of ten to twenty of these nodes fused 
together by inflammatory products, completely surrounding the trachea 
and both the large bronchi. It is rare that the individual glands are 
more than an inch in diameter, and most of them are smaller than this. 



./-' 



*fti 



0- 





Fig. 176. — Tuberculous bronchia] lymph nodes. Section of the lung of an infant through 
cheesy bronchial lymph nodes at the root of the lung, and adjacent cheesy masses, several 
of which have softened at the centre; the lung otherwise normal; life-size. (After 
Northrup.) 

A well-marked but not unusual example of this condition is shown in 
Plate XIX. There is usually found a chain of these tuberculous glands 
following the course of the large bronchi for some distance into the lung; 
sometimes these are almost as large as the external group (Fig. 176) ; at 
other times they are not noticed unless a somewhat careful dissection is 



1030 THE SPECIFIC INFECTIOUS DISEASES. 

made. The process is not infrequently more advanced in these deeply- 
seated glands than in those situated at the root of the lung ; and lesions 
here are also more important, as it is very frequently through them that 
the lung becomes infected. 

The pathological changes through which these glands pass as a result 
of tuberculous infection, are very similar to those already described with 
reference to the cervical glands (page 825). Suppuration is less frequent 
than in the region of the neck, while calcific degeneration is much more 
so. This applies especially to children over three years old. In infancy 
suppuration is not infrequent in the bronchial glands, while at this age 
calcification is extremely rare. Infection of these lymph glands is not 
always followed by general tuberculosis or even by infection of the lung. 
Although the process has gone on to caseation, these inflammatory prod- 
ucts with bacilli may become encapsulated, and may remain innocuous for 
an indefinite period. The bacilli may die or may exist here, living, for 
years. At any time the old process may be lighted up, and a more or less 
rapid dissemination of tubercle bacilli take place through the lungs or 
through the whole body. Latent tuberculosis more frequently exists in 
the bronchial lymph nodes than in any other structure in the body. 

Secondary lesions may be produced by these lymph nodes. The 
pneumogastric and recurrent nerves may be surrounded by one of these 
cheesy masses which causes pressure and irritation. The oesophagus, the 
trachea, or the bronchi, may be compressed or opened by ulceration. The 
superior vena cava usually suffers only compression, but this or any of the 
other large vessels may be opened. Ulceration may also take place into 
one of the large or small bronchi or the trachea. If the gland has softened 
and broken down, and if the bronchus is a small one, the only result of 
this may be a rapid spreading of tuberculous infection throughout the 
lung. If sudden rupture occurs, a large caseous mass may escape into the 
trachea, or a large bronchus, with a result similar to that produced by any 
other foreign body. If suppuration occurs, the abscess may rupture into 
the surrounding cellular tissue, causing mediastinal or retro-oesophageal 
abscess (page 276). This may open externally at the suprasternal notch, 
or in the first or second intercostal space, or may ulcerate into any of the 
large vessels, the oesophagus, or the pericardium, or may burrow down- 
ward into the peritoneal cavity. 

Pleura. — This is rarely normal in any case of tuberculosis. In acute 
general tuberculosis the only lesion may be a deposit of miliary tubercles 
upon the visceral pleura. In most of the other cases there are found 
fibrous adhesions over the part of the lung involved, binding it to the 
pericardium, the diaphragm, or the chest wall. The amount of thicken- 
ing of the pleura varies a good deal, but is rarely great. In about one 
fifth of my own autopsies tuberculous nodules were found in the pleura •> 
with these lesions there is usually considerable thickening. Pleurisy with 



TUBERCULOSIS. 1031 

a hemorrhagic exudation is very rare in the tuberculosis of early child- 
hood. Empyema is also rare, being seen in but five per cent of my 
cases, and then it was small and sacculated. Pneumothorax and pyo- 
pneumothorax are very rare in children under three years of age ; they 
were not seen in any of my cases. 

Heart. — It is exceptional for the pericardium to be affected even in 
the most generalized forms of miliary tuberculosis. In such cases the 
usual lesion is a deposit of a few gray tubercles upon the visceral surface. 
In chronic cases other lesions analogous to those of the pleura may be 
seen, but all are rare in childhood. In a single instance I have seen 
miliary tubercles upon the endocardium. They are extremely rare, and 
the development of cheesy nodules in the heart is almost unknown in 
early life. 

Brain. — Tuberculosis of the brain is not uncommon during infancy, 
being then associated in nearly all cases with general tuberculosis, and 
especially with tuberculous pneumonia ; but it is relatively twice as fre- 
quent after the second year. There may be found miliary tubercles alone, 
or these may be accompanied by inflammatory products — tuberculous 
meningitis — or there may be caseous nodules. Miliary tubercles are fre- 
quently found in small numbers in cases which have presented no symp- 
toms. The lesions of tuberculous meningitis have already been described 
(page 715). Cheesy nodules are rare in infancy, being noted in but 2'5 
per cent of my own autopsies, which were mainly on children under three 
years old ; while in the Pendlebury Hospital cases, including those between 
four and twelve years old, they were noted in 24*4 per cent. These nod- 
ules vary in size from a pea to a child's fist ; they are usually associated 
with tuberculous meningitis, but they may exist alone. When they are 
large they rank as cerebral tumours, being most frequently seen in the 
cerebellum. They rarely soften, but may be the seat of calcareous deposits. 

Liver. — This is frequently involved in general tuberculosis, although it 
is doubtful if it is ever the seat of primary infection except in the con- 
genital cases. Usually the only lesion is the presence of miliary tubercles 
on its surface and in its substance, and in most cases these are not numer- 
ous. They are found in about two thirds of the cases. In a smaller 
number there are tuberculous nodules of various sizes. In nearly every 
protracted case the liver is markedly fatty. In very late cases of tubercu- 
losis of the bones, it is frequently the seat of amyloid degeneration. 

Spleen. — This is more frequently affected than the liver, but in very 
much the same way. In most of the cases of general tuberculosis, miliary 
tubercles are present in the spleen, these being usually numerous, both 
upon the surface and throughout the organ. Not infrequently small tuber- 
culous nodules are also seen, but there are rarely any which are larger than 
a pea. The size of the spleen is not altered if only miliary tubercles are 
present ; but with the tuberculous nodules it may be much enlarged. 



1032 THE SPECIFIC INFECTIOUS DISEASES. 

Amyloid degeneration is found under the same conditions as in the 
liver. 

Stomach. — Tuberculosis of the stomach is one of the rare lesions ; both 
its contents and its acid reaction seem to protect it against direct infection 
from the mouth. Tuberculous ulcers were seen in five of my autopsies, 
which is a larger proportion than is usually noted. 

Intestines. — These are less frequently affected in infancy than in older 
children, which is rather surprising when we consider how susceptible are 
the intestines of infants to other forms of infection. The explanation of 
this difference seems to me to be this : Intestinal infection is nearly always 
secondary to disease of the lungs ; primary lesions being extremely rare. 
Infants usually* die from the more rapid tuberculous processes in the 
lungs or brain before there has been time or opportunity for intestinal 
infection to occur. The opportunities for such infection depend upon the 
number of bacilli which are coughed into the pharynx and swallowed. In 
infancy this number is small, because of the many who die of tuberculous 
pneumonia or meningitis before extensive softening in the lungs has taken 
place. In older children the slower course of the pulmonary disease gives 
ample time for intestinal infection, while the more extensive softening and 
excavation are accompanied by the discharge of a much larger number of 
bacilli. The intestinal lesions and those of the mesenteric lymph nodes 
with which they are almost invariably associated, are described on page 361. 

Peritonaeum. — In infancy the peritonaeum is not often involved even 
in general tuberculosis, and at this age it is very rare for it to be the seat 
of the principal tuberculous process. This occurred but once in my own 
119 autopsies. In older children it is more frequent; of the 131 Pendle- 
bury Hospital cases, the peritonaeum was involved in 37, or twenty-eight 
per cent. In most cases of general tuberculosis there are only deposits 
of miliary tubercles ; less frequently there are tuberculous nodules with 
other inflammatory products. The lesions in these cases are described with 
Diseases of the Peritonaeum (page 420). 

Thymus gland. — In three of my cases tuberculous nodules were found 
in the thymus body, the size varying from a small pea to a hazelnut. 
Some of the largest nodules had undergone softening at the centre. All 
these were cases showing widely disseminated tuberculous lesions. 

Pancreas. — In three of my cases this organ also was the seat of small 
tuberculous nodules, all of them being cases of general tuberculosis. 

Uro-genital organs. — Serious tuberculosis of any part of the urinary 
tract is very rare in children. Miliary tubercles were found in the kid- 
neys in about one third of my autopsies on tuberculous patients. They 
are generally few in number. Tuberculous nodules of the kidney I have 
seen but once in a young child. They are very rare before the fourteenth 
year (page 623). In two of my autopsies tuberculous nodules were found 
in the suprarenal capsules. Tuberculosis of the testicle has been observed 



THE CLINICAL FORMS OF TUBERCULOSIS. 1033 

in rare instances among children, although not in one of my own series. 
Koplik (New York) has reported several cases. 

Tuberculosis of the bones and of the external lymph nodes have al- 
ready been described (pages 825 and 837) 

THE CLINICAL FORMS OF TUBERCULOSIS. 

I. General Tuberculosis. — C&ses of tuberculosis present a wide 
variety in their symptomatology. Almost every case possesses some pecul- 
iar features which depend upon the constitution of the patient, the source 
of infection, the rapidity with which the bacilli are disseminated through 
the body, or the numbers in which they enter. The general symptoms 
usually precede the local ones, but in probably the majority of cases they 
are masked and unrecognised. It is not often possible to recognise tuber- 
culosis until the process is quite well advanced in some one organ. The 
early symptoms in most cases are very indefinite and susceptible of many 
-explanations. 

1. Cases Resembling Infantile Marasmus. — In early infancy, tubercu- 
losis often gives at first and for a long time only the symptoms of maras- 
mus. Infants are pale and thin, they do not gain in weight, and finally 
hecome emaciated. There is nothing characteristic about these symp- 
toms, and it should be remembered that they depend much more fre- 
quently upon simple marasmus than upon tuberculosis. There may be no 
cough and no fever sufficient to attract attention, and the case may even 
go on to a fatal termination without any symptoms except those of in- 
fantile marasmus. This I have seen at least a dozen times in cases that 
came to autopsy. 

More frequently, however, there are developed toward the end of the 
disease both the symptoms and signs of pulmonary disease and fever. 
These are generally found together, as the process in the lungs is the cause 
of the rise of temperature. The febrile symptoms are often not seen until 
the last two or three weeks of life. The course of the temperature is ir- 
regular. It is never of the hectic type and rarely high. The usual range 
is between 100° and 102° F. The pulmonary symptoms are generally few 
and not very well marked. There is usually some cough, but it is rarely 
severe. The breathing is more rapid than would be explained by the 
temperature alone. Severe dyspnoea and cyanosis are rare, and are seen 
only at the close of the disease. The physical signs are those of either 
localized bronchitis or of broncho-pneumonia. 

The other symptoms usually relate to the digestive tract. There may 
be indigestion, with occasional vomiting and green undigested stools, or 
there may be diarrhoea. The intestinal symptoms depend on the general 
condition of the child and the constitutional disease, rarely upon a tuber- 
culous process in the stomach or bowels. 

If the case has gone on to the development of constant fever and rec- 
76 



1034 THE SPECIFIC INFECTIOUS DISEASES. 

ognisable physical signs which slowly spread, the infant's fate is sealed. 
The progress of the case from .this time is steadily downward, and the 
child can live at most but a few weeks. Death generally occurs from pro- 
gressive asthenia without the development of any new symptoms. Occa- 
sionally toward the close, cerebral symptoms rapidly develop, and the 
child is carried off in a few days by tuberculous meningitis ; sometimes 
there is a rapid spreading of the disease in the lungs, and death occurs 
with symptoms of simple acute pneumonia. 

Diagnosis. — The difficulty in diagnosis is chiefly during the first year 
of life. Every circumstance in the patient's surroundings and family 
history which bears upon the development of tuberculosis must be 
weighed to establish the fact of inheritance or of exposure to contagion. 
In simple wasting, the usual history is that the infant was plump and well 
nourished at birth. A sufficient cause for its condition can in most 
cases be found in improper or insufficient nourishment or the want of 
proper care. (See causes of marasmus, page 204.) Often the wasting- 
follows some acute disease of infancy, most frequently some form of gas- 
trointestinal disease. 

In tuberculosis, the infant may show all the signs of malnutrition at 
birth, but in most cases they are of later development. They either come 
without adequate cause, or are associated with pulmonary disease or they 
follow measles or pertussis. No explanation of the wasting can be dis- 
covered in the food, the surroundings, or in the condition of the digestive 
organs. Diarrhoea and vomiting more frequently follow than precede it. 
The above facts are sufficient to warrant a suspicion only that tubercu- 
losis is present until some local manifestation occurs, usually in the lungs. 
The early wasting without adequate cause, followed by the gradual devel- 
opment of low fever, and finally the appearance of signs of subacute 
broncho-pneumonia, form the most characteristic features of general tu- 
berculosis in early infancy.- Yet all these symptoms are occasionally met 
with in cases in which the autopsy shows none of the lesions of tubercu- 
losis, for simple broncho-pneumonia frequently occurs in patients suffer- 
ing from marasmus ; but in such cases fever is usually slight and it may 
be absent. 

The wasting and cachexia of hereditary syphilis sometimes resemble 
tuberculosis, but the early history in syphilis is usually so characteris- 
tic, and other symptoms of the disease are so rarely wanting, that the 
mistake is not likely to be made if a patient is submitted to a careful ex- 
amination. In the absence of definite syphilitic symptoms the chances 
are greatly in favour of tuberculosis. 

2. Cases in Older Children with Symptoms Resembling a Continued 
Fever. — Before the development of fever in these cases, there is usually 
quite a protracted period of very indefinite symptoms, each one of which 
alone is unimportant, but all of which taken together should excite sus- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1035 

picion. Such children are usually delicate ; they are persistently anaemic 
without sufficient reason ; they often show a loss in weight ; there is a 
marked cachexia, sometimes a capricious appetite, and a digestion easily 
disturbed. In some of them a change in disposition is observed, and 
they become peevish or fretful and are disinclined to muscular exertion. 
All these symptoms indicate a gradual decline in the general health. 

This clinical picture may be due to many causes, but it should always 
arouse in the mind of the physician a suspicion of incipient tuberculosis, 
particularly in a child who by surroundings or inheritance is predisposed 
to that disease. After these indefinite symptoms have lasted a few weeks 
fever is added. Sometimes the prodromal symptoms are absent or 
unnoticed and fever is the first evident symptom. This fever is peculiar 
in that it comes without evident cause and without any local manifesta- 
tions of disease. The temperature is not often high, but it is continuous. 
The tympanites and the rose-coloured spots are not present, but the gen- 
eral aspect of the patient is strikingly like that belonging to typhoid 
fever. 

After the fever has lasted from one to three weeks there develop some 
signs of localized tuberculosis, generally in the lungs, or the fever may 
decline gradually, and although the patient improves he does not get 
well. He is still weak and does not gain in weight, and the thermometer 
shows the existence of a very slight amount of fever. Before long he 
may grow rapidly worse and the course of the temperature becomes irreg- 
ular, with alternate exacerbations and remissions. Such an irregular and 
inexplicable fever sometimes puzzles the physician for three or four weeks 
before the characteristic features which stamp the process as tuberculous 
are present. One general symptom is almost invariably associated with 
the fever, viz., wasting. This may not be rapid, but is progressive. The 
tuberculous cachexia is frequently unmistakable ; but in most of the cases 
one must wait for the process to advance far enough in some one of the 
organs to give local signs or symptoms before he can be sure of tuberculo- 
sis. In four cases out of five this is in the lungs. Less frequently it is 
in the peritonaeum, the brain, or a general infection of the lymph glands 
throughout the body. If in the lungs, the process manifests itself as a 
broncho-pneumonia whose tuberculous character may be suspected from 
its localization — the apex or the middle of the lung in front — but chiefly 
from the fact that the general symptoms, fever and wasting, have for so 
long a time preceded the local signs of disease. From this time, the 
course of the disease may be that of a typical tuberculous broncho- 
pneumonia. 

If the tuberculous process is localized in the brain, we have dulness, 
vomiting, headache, apathy, irregular pulse, irregular respiration, and 
finally convulsions and coma — in short, the symptoms of tuberculous 
meningitis; if in the peritonaeum, we have abdominal distention from 



10 36 THE SPECIFIC INFECTIOUS DISEASES. 

gas or fluid, tenderness, pain, diarrhoea, or constipation ; if in the lymph 
glands, there is a general enlargement of those situated in the neck, and 
sometimes those of the axillary and inguinal regions, with symptoms indi- 
cating similar changes in those at the root of the lung. 

Diagnosis. — In distinguishing general tuberculosis from typhoid fever, 
very great stress is to be laid on the family and previous history of the 
patient and the surroundings, as favouring tuberculosis. On the other 
hand, the prevalence of typhoid fever in the family, the neighbourhood, 
or the institution in which the case occurs, is important. The extreme 
infrequency of typhoid in children under two years old should always 
lead the physician to scrutinize very carefully every case in which he is 
disposed to make such a diagnosis at that time of life. In typhoid, the 
course of the fever is more regular than in tuberculosis, but less so than 
in the typhoid of adults, and the spleen in nearly every case is sufficiently 
enlarged to be easily felt below the ribs. The rose spots are usually pres- 
ent, and these with the swollen abdomen and diarrhoea make the diagno- 
sis, at least after the middle of the second week, quite clear in most cases. 
The most decisive feature, however, is the gradual cessation of the fever 
in the third or fourth week and complete recovery of the patient. 

In tuberculosis, on the contrary, the fever is less regular. It common- 
ly shows wider fluctuations, the spleen is not usually enlarged, and there 
are no rose spots. Tympanites and abdominal tenderness are sometimes 
seen, but the fever shows no disposition to stop after the third week, 
and the wasting is continuous. The signs in the lungs, at first few, in- 
crease from day to day. In most cases one must wait for ten days at 
least, and in many three weeks, before a positive diagnosis can be made. 

II. Tuberculous Brox cho-Pneumokia. — This occurs clinically un- 
der the following conditions : (1) It may begin in the lungs or extend to 
the lungs from the bronchial glands, the symptoms in either case being 
essentially pulmonary from the outset. (2) It may follow either form 
of general tuberculosis described — that resembling marasmus in infants, 
or that resembling a continued fever in older children. In both of these 
the pulmonary symptoms develop gradually in the course of the general 
symptoms of the disease. (3) It may occur in the course of any of the 
forms of local tuberculosis, — of the bones, peritonaeum, intestines, external 
lymph glands, or skin. In such cases the invasion of the lungs frequently 
marks the last stage of the process. (4) It may follow any of the infec- 
tious diseases, especially measles or pertussis, even though they are not com- 
plicated by broncho-pneumonia, but more frequently when they are. (5) 
It may follow single or repeated attacks of simple bronchitis or pneumonia. 

Clinically the cases may be divided into three groups : First, the most 
rapid ones, lasting from one to three weeks ; secondly, those running a 
more protracted course, with a duration of from three weeks to three 
months ; thirdly, those which are more or less chronic. In the first two 



THE CLINICAL FORMS OF TUBERCULOSIS. 1037 

groups the progress is nearly always steadily downward, and a fatal ter- 
mination the almost inevitable result ; in the third form the course is more 
irregular, and marked by a series of exacerbations and remissions. 

1. The Most Rapid Cases. — In this form of the disease there are found 
scattered through certain portions or nearly the whole of both lungs, mili- 
ary tubercles and minute tuberculous nodules, the intervening parts of 
the lung being involved more or less seriously in a simple inflammation. 
In most of the cases the clinical picture is that of simple acute broncho- 
pneumonia, for it is to the accompanying broncho-pneumonia, and not to 
the scattered tuberculous deposits themselves, that the symptoms and the 
physical signs are due. The development of the disease, although acute, 
is not usually abrupt. There are present, fever, cough, dyspnoea, acceler- 
ated respiration, prostration, and sometimes cyanosis. The temperature 
in these cases is never hectic, but its course is a somewhat irregular one 
the usual range being between 100° and 104° F. In most of the cases it 
differs in no respect from the temperature of simple broncho-pneumonia. 
Sometimes it is seen that the general symptoms are severe and the phys- 
ical signs wide-spread, and yet the range of temperature is not high. To 
be sure, this is occasionally seen in a simple broncho-pneumonia, but it is 
more frequent in tuberculosis. The cough early in the disease is slight, 
but later becomes severe and often distressing. In infants and young 
children it may be of a paroxysmal character, resembling pertussis. Ex- 
pectoration is wanting in infancy, and is not often seen in those under 
seven years, so that bacilli in the sputum is a symptom of only a small 
number of cases. Bloody expectoration, likewise, is rare in children. 

The conditions in the lungs which give physical signs are bronchitis 
of the smaller tubes, with areas of complete or partial consolidation. In 
character, these signs are identical with those of simple broncho-pneu- 
monia (page 4-99). They may be scattered throughout the whole of both 
lungs ; but when localized they are more frequently in the upper than in 
the lower lobes, and rather more frequently in front than behind. Al- 
though both lungs are involved, they are usually not affected to the same 
degree. The patient may die before signs of complete consolidation are 
present; more often there are during the last few days small areas of 
partial consolidation, as shown by broncho-vesicular breathing, exagger- 
ated voice, and slight dulness. These signs are usually due to the simple 
broncho-pneumonia, and are likely to be found in the lower lobes behind. 
Large areas of complete consolidation, with pure bronchial breathing, 
bronchial voice, and marked dulness are infrequent. 

From the beginning of acute symptoms the progress of the disease is 
steadily downward, death resulting from the same causes as in simple 
broncho-pneumonia. The end is marked by cyanosis, greal dyspnoea, 
weak pulse, and extreme prostration. In a few cases there develop shortly 
before death cerebral symptoms, indicating tuberculous disease of the 



1038 



THE SPECIFIC INFECTIOUS DISEASES. 



brain. Such symptoms may be the first to lead the physician to suspect 
the process to be a tuberculous one. In these cases death may occur in 
convulsions in two or three days from the first cerebral symptoms. In 
other cases the course is slower, with the typical symptoms of meningitis. 
2. The More Protracted Cases. — In this form of the disease there are 
found in the lungs caseous nodules, with larger areas of caseous pneu- 
monia, and usually some spots of softening. The process is not usually so 
generalized as in the cases just described, but as in them there is always 



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3 


4 


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Fig. 177.— Tuberculosis following measles. Child sixteen months old, inmate of an institu- 
tion. Chart begins on fifth day of a severe but uncomplicated attack of measles, and shows 
a natural decline to normal. Fever then returned and continued till death, twelve weeks 
later. Eecord for the period which is omitted was much like that which immediately pre- 
cedes and follows. Early symptoms not acute, only slow wasting, slight cough and fever, 
with scattered rales throughout chest. Signs of consolidation not distinct till eighth week, 
then present in right upper lobe. Toward the end, rapid emaciation, marked pulmonary 
symptoms, and signs of cavity at right apex. Autopsv showed a lar^e cavity, extensive 
tuberculous deposits throughout both lungs and in nearly all abdominal organs. ' 

associated a certain amount of simple pneumonia. This is the most fre- 
quent and most characteristic form of pulmonary tuberculosis in infancy 
and early childhood. Its usual duration is from one to three months ; its 
course is then steady and uninterrupted. In its slower or subacute form 
it lasts from three to six months, and its course is then more irregular. 

The mode of onset will depend upon the conditions under which the 
disease develops. When the general symptoms of tuberculosis — fever and 
wasting, — have preceded those in the lungs, the evolution of the latter 
is gradual, with cough, rapid breathing, dyspnoea, increased prostration, 



THE CLINICAL FORMS OF TUBERCULOSIS. 



1039 



etc. When the pulmonary symptoms are present from the beginning, they 
are the same as in simple broncho-pneumonia, with the exception that they 
usually come on less acutely. The latter is true of cases which are second- 
ary to some other form of tuberculosis in the bones, peritonaeum, etc. 

"When pulmonary tuberculosis follows measles (Fig. 177) or whooping- 
cough which have been complicated by simple pneumonia, the early symp- 
toms may present no unusual features. After two or three weeks the tem- 
perature gradually falls, and the physical signs improve, but neither quite 
disappears. The cough continues, though its severity somewhat abates. 
In the course of a few weeks the child, who has meanwhile improved some- 
what in his general condition, becomes distinctly worse, often without any 
assignable cause. The temperature rises to 102° or 103° F. ; the cough 
increases, and an extension of the disease in the lungs is evident by the 
physical signs. In other cases the progress of the disease after the pneu- 
monia which complicated measles is without an intervening period of 
apparent improvement. It sometimes happens that the attack of measles 
or whooping-cough is not accompanied by any serious pulmonary symp- 
toms, and the case goes on to apparent recovery, except that there remain 
anaemia, a slight cough, and fever. The temperature, although not high, 
persists ; but it may be two or three weeks before there are present definite 
symptoms and signs of disease in the lungs. 

Fever is a constant accompaniment of all active tuberculous processes 
in the lungs in the child as in the adult, it being absent only during the 
periods of remission which occur in the cases of slow and irregular prog- 



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Fig. 178. — Tuberculous pneumonia, general tuberculosis. Patient eleven months old, and ander 
observation at the time lie was taken sick. Chart of entire illness is given. Disease began 
as an acute pneumonia in lower part of left axilla and spread to entire Lower lobe. Early 
signs of consolidation; at end of two weeks, flatness bo marked that a needle was inserted, 
fluid being BuspectecL Vomited frequently, and bad loose discharges from bowels through- 
out the illness; abdomen much swollen for last two weeks. Autopsy showed cheesy pneu- 
monia of part of the upper and the entire left lower lobe, where were two small cavities. 
Recent tubercles found throughout right Lung, and extensive deposits in abdominal organs 
with peritonitis, intestinal ulcers, 

ress. It is a very important guide to the progress of the disease. The 
early fever depends chiefly upon the coexisting broncho-pneumonia, 
and its course resembles that of simple pneumonia of the protracted 
variety. There is no typical curve. The fever is not often steadily high, 
and in many cases it is never higli (Fig. 178). It frequently runs for 



1040 



THE SPECIFIC INFECTIOUS DISEASES. 



several days between 99° and 102° F., and then, without evident cause T 
rises to 104° F. or over ; again, it may be scarcely over 100° F. for days 
together. In infants the morning temperature is frequently subnormal, 
although the evening temperature may be 102° or 103° F. Even toward 
the close of the disease, when softening and breaking down are actively 
going on, the regular hectic temperature of adults is rarely seen in a 
young child (Fig. 179). While the presence of fever is of great signifi- 



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Fig. 179. — Tuberculous pneumonia, with extensive softening and excavation. A delicate child, 
thirteen months old ; weight, ten pounds ; came under observation four weeks before death, 
with consolidation at apex of right lung. Signs increased in intensity, and extended in area 
until there were heard, from clavicle to below the nipple — exaggerated bronchial voice and 
breathing and many moist rales ; percussion note was flat ; behind, the same signs at ex- 
treme apex. No distinct signs of a cavity ; no hectic fever; no sweating. Autopsy showed 
large cavity (Fig. 173) at right apex partly filled with caseous masses ; diffuse caseous pneu- 
monia (Fig. 172) of the rest of right upper lobe, with scattered deposits in the other lobes, 
the opposite lung, and a few in the abdominal organs. 

cance, its course has almost no diagnostic importance in early life. Espe- 
cially should one beware of drawing the conclusion that, because the fever 
is not hectic, therefore there is no breaking down of the lung. 

Sweating belongs only to the late stage of the disease, and is usually 
associated with the hectic type of fever ; both these are regular symptoms 
in children over seven years old, but not in very young children. 

Wasting, like fever, is characteristic of all active tuberculous processes. 
Whenever they are associated, tuberculosis should always be suspected, 
no matter how obscure the other symptoms may be. The wasting is not 
always rapid, but it is usually continuous while fever lasts. During the 
periods of temporary improvement, children may not only cease to lose, 
but may actually gain in weight. In the early stage of the disease, wast- 
ing is especially suggestive when it continues without apparent cause 
after measles or pertussis, or when it persists under other circumstances 
in spite of a good appetite and apparently good digestion. It may at 
first be so slight as not to be noticed unless the scales are employed. In 
obscure cases this steady loss of weight is a point of much diagnostic 
value, and is frequently overlooked. Toward the close of the disease there 
is rapid and frequently extreme emaciation. 

Cough, although almost invariably present, shows no peculiarities. It 
may be hard, dry, or suppressed ; it sometimes occurs in paroxysms re- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1041 

sembling pertussis, which may or may not depend upon the presence of 
enlarged bronchial glands. 

Expectoration is absent in infants, the matters coughed up being 
swallowed. In children over seven years old, we often get a profuse muco- 
purulent expectoration, but it is very exceptional below this age. 

Haemoptysis is a rare symptom, but not unknown even in young chil- 
dren. Henoch has reported a case of fatal haemoptysis in a child ten 
months old, where the haemorrhage was due to the rupture of an aneurism 
in the wall of a cavity. Herz, in 247 clinical cases of tuberculosis in chil- 
dren, records 8 of haemoptysis — 4 of them under five years, and the young- 
est only eighteen months old. The records of 131 autopsies on tubercu- 
lous children in the Pendlebury Hospital, show that haemoptysis was four 
times a cause of death ; two of these patients were under five years, and 
one was only twelve months old. I have never met with a case of haemop- 
tysis under five years old. As in adults, fatal haemoptysis is usually due 
to the opening of a large vessel by ulceration in the wall of a cavity, which 
is sometimes in the lung and sometimes in one of the bronchial glands. 

The respiration in all cases of tuberculous pneumonia is accelerated, 
and usually out of proportion to the rise in temperature. As the lung 
becomes more and more extensively invaded there is constant dyspnoea. 
The pulse is rapid in the early stage, and continues so throughout the 
disease ; toward the end it becomes weak and irregular. Irregular respi- 
ration and a slow, irregular pulse, may occur at any time from the develop- 
ment of cerebral complications. 

Pleuritic pains in the chest are not frequent in children. Gastroin- 
testinal symptoms, such as indigestion, vomiting, diarrhoea, etc., are gen- 
erally present, but are not peculiar in this disease. They usually depend 
upon the patient's general condition, only exceptionally upon tuberculous 
disease of the stomach or intestines. The characteristic symptoms of 
intestinal tuberculosis — abdominal pain, tenderness, uncontrollable diar- 
rhoea, and intestinal haemorrhage— are not often met with in children 
under five years. With such symptoms, and sometimes when they are 
doubtful or absent, careful palpation of the abdomen may disclose the 
presence of enlarged mesenteric glands. When these are not readily felt 
through the abdominal walls, they may sometimes be discovered by a rec- 
tal examination after the method of Carpenter (London). 

The spleen is often enlarged, sometimes very much so, but this does 
not occur with sufficient frequency to be of much diagnostic value. It 
may be due to tuberculous deposits, to causes connected with the lungs or 
heart, or to fever. The liver is never enlarged from tuberculous deposits, 
but may be so from amyloid or fatty degeneration, or from obstructed 
circulation, as in the case of the spleen. 

Dropsy is rare and seen only toward the close of the disease. It may 
depend upon anaemia, upon complicating nephritis, especially amyloid de- 



1042 THE SPECIFIC INFECTIOUS DISEASES. 

generation, upon cardiac or pulmonary conditions leading to interference 
with the return circulation, or upon pressure of tuberculous retro-perito- 
neal or mesenteric glands upon the inferior vena cava. Clubbing of the 
fingers is occasionally seen in cases running a very protracted course, and 
is due to obstructed circulation. 

Auaemia is commonly associated with wasting, and it is of special im- 
portance where the latter is slight or absent. It is a frequent sequel of 
acute disease in infancy when not dependent on tuberculosis ; when, how- 
ever, it is associated with low fever, cough, and persistence of rales in the 
chest, it should always excite apprehension. 

3. Chronic Tuberculous Pneumonia. — In young children this is a chronic 
interstitial pneumonia associated with tuberculous deposits. These cases 
have usually had their beginning in one of the more acute forms just de- 
scribed. The primary attack runs a tedious, protracted course ; there are 
a slow convalescence and apparent recovery, although this is not complete. 
Often a slight cough remains, or returns from the slightest exposure or 
other exciting cause. The child does not regain his former weight or 
vigour, and careful examination of the lungs shows that some abnormal 
signs remain. There are frequently present feeble breathing and slight 
dulness over the affected part of the lung, and occasionally friction- 
sounds may be heard. 

After a few months, possibly, the child has another attack resembling 
the first and running the same tedious course. It is accompanied by fever, 
cough, and perhaps there is a fresh consolidation of some part of the lung, 
generally in the neighbourhood of the old disease. All active symptoms 
finally subside, and most of the signs of recent disease disappear; but it is 
usually found then that the lung is not quite in so good condition as it 
was before this second illness. The acute attacks may be repeated several 
times and pass under the name of bronchitis, broncho-pneumonia, or 
pleurisy. They may extend over a period of two or three years or even 
longer. The general health in the interval is not good, there being present 
in most cases anaemia, with the usual symptoms of malnutrition ; the chil- 
dren are regarded as being very delicate. 

The course of this disease thus differs in no essential particulars from 
that of simple chronic broncho-pneumonia (page 535) ; the physical signs 
likewise are identical in character, although they may differ in their loca- 
tion. They are generally found in the same situations as are the signs in 
the more rapid forms of pulmonary tuberculosis in early childhood. A 
fatal result in these cases is usually brought about in one of three ways : 
(1) by the development of acute tuberculous pneumonia or miliary tuber- 
culosis of the lungs, occurring with the symptoms of one of the previous 
exacerbations which has come on without apparent cause or perhaps has 
followed an attack of measles or whooping-cough ; (2) by tuberculous 
meningitis ; (3) by a simple acute broncho-pneumonia. 



THE CLINICAL FORMS OF TUBERCULOSIS. 1043 

Physical Signs of Tuberculous Pneumonia. — Speaking generally, there 
is no difference in a young child between the signs of a tuberculous and 
those of simple broncho-pneumonia except in their position ; for cavities, 
although they are present at autopsy in most of the cases, are very rarely 
of such size and so situated as to be recognised during life. In children 
over seven or eight years old, and sometimes in those of five or six, the 
signs are essentially like those in adults. 

By reference to the description of the lesions (page 1023) it will be 
noted that the upper lobes are the seat of the most advanced disease twice 
as frequently as the lower lobes, and the right lung rather more frequently 
than the left. When the disease is in the upper lobes it is rarely at the 
extreme apex, and when it is in the lower lobes it is very exceptional to 
find it at the base, posteriorly. The region most often involved is the 
middle zone of the lung. If the signs appear first behind they are, in the 
great majority of cases, in the interscapular space ; if in the lateral part 
of the chest, they are in the middle or upper part of the axilla ; if in 
front, they are in the mammary region, more frequently above than below 
the nipple, but rarely extending quite to the clavicle. In other words, it 
is near the root of the lung that the disease most frequently begins, spread- 
ing thence forward more often than backward. The explanation of this 
is found in the fact that the disease in infants and young children so often 
extends from the lymph nodes at the root of the lung to the lung itself. 
The physical signs themselves may be grouped under four heads, corre- 
sponding to the pathological conditions existing in the various stages 
of the disease — viz., (1) localized bronchitis; (2) partial consolidation; 
(3) complete consolidation ; (4) excavation. The early signs in the first 
two stages are identical with those described in broncho-pneumonia (page 
499), those of the third stage being the signs of the persistent form (page 
502). As a rule, however, the transition of the signs from one stage to 
another is much slower in tuberculous than in simple broncho-pneumonia. 

As stated in the description of the lesions, cavities are found in the 
lungs in the majority of cases of infants dying from tuberculosis of the lungs. 
It is, however, rare that they can be recognised in children under three 
years old. From three to eight years they give more positive signs, and 
after eight years practically the same signs as in adults. The reason why 
in infancy cavities are so seldom recognised during life is because they 
are generally small, often centrally located, nearly always filled with thick 
pus or cheesy matter, and rarely communicate freely with the bronchi. 
On the other hand, it is very common to find signs in young children 
which, if heard in adults, would be regarded as almost positive evidence of 
a cavity, although none is present. These signs are cracked-pot reso- 
nance and cavernous breathing. They are not usually due to bronchi- 
ectasis, since this condition belongs to chronic cases, and especially to 
older children; but most frequently to consolidation about a large bron- 



1044 THE SPECIFIC INFECTIOUS DISEASES. 

chus superficially situated — viz., below the clavicle, high in the axilla and 
in the interscapular region. The wide area over which this broncho-cav- 
ernous breathing is heard, is one of the most striking points of difference 
from the signs of a cavity. 

Course, Duration, and Termination. — Whatever may be the evolution 
of the symptoms, and the variations are almost endless, the cases fall readily 
into two groups, — those in which the progress is rapid and steady and those 
in which it is slow and intermittent. The duration of the first group is 
from four to eight weeks. Fever is constant, wasting progressive, and the 
physical signs show a steady advance of the disease in the lungs. Dyspnoea 
becomes severe and constant ; the pulse grows more and more rapid and 
feeble ; and death occurs from exhaustion, pulmonary oedema, or syncope, 
less frequently from meningitis. 

In the second group the duration is from two to six months. The 
course can not better be described than as a succession of attacks of 
broncho-pneumonia, sometimes separated by an interval of several weeks, 
at other times one coming on before the first is fairly over. During 
exacerbations the symptoms resemble those of the first form, there being 
marked fever, wasting, cough, and dyspnoea. The child may seem hope- 
lessly ill when, without any special reason, a change for the better occurs, 
the acute symptoms abating and the signs of consolidation in great measure 
disappearing. Toward the end of the disease the pulmonary and consti- 
tutional symptoms become constant, and frequently there are added symp- 
toms due to extension of the tuberculous process to other parts of the 
body — the brain, peritonaeum, intestines, mesenteric glands, etc. These 
cases die, as do the more acute ones, from the local disease in the lungs 
or from general infection. 

Diagnosis. — The evidence upon which a diagnosis of tuberculosis is 
made, is of two kinds, — that which relates to the patient and that which 
relates to the local disease. In any case, a diagnosis is reached by weigh- 
ing the evidence as a whole rather than by relying upon the presence of 
particular symptoms or physical signs. One should investigate the family 
history, surroundings, and previous condition of the patient ; also the 
mode of onset, and course of the disease, and consider the evidence 
afforded by the examination of the patient. 

A careful examination of the family history should be made to deter- 
mine, first the existence of phthisis in the parents or in other members of 
the family, near or remote. Children more often inherit tuberculosis 
from the mother than from the father, and are more likely to contract it 
from her, owing to the closer contact. It is not enough simply to inves- 
tigate the question of phthisis. Inquiry should be made regarding menin- 
gitis, disease of the cervical glands, spine, hip, knee, or ankle, especially in 
the other children of the family. These points are important not only to 
establish the fact of heredity but also the probable chances of exposure. 



THE CLINICAL FORMS OF TUBERCULOSIS. 1045 

Other conditions favourable for acquiring the disease should be considered, 
such as in a private family exposure to nurses or other members of the 
household ; also whether the surroundings have been such as would give 
opportunities for infection, as in cases where a child has been reared in a 
tenement house, or has been long an inmate of a hospital or other institu- 
tion. In the child's previous history, it is important to know whether 
there have been other manifestations of tuberculosis in the cervical glands, 
spine, hip, knee, or ankle, or the skin ; also whether he has been liable to 
attacks of severe or protracted bronchitis or broncho-pneumonia. If he 
has had measles or pertussis, it is important to know whether they were 
severe, accompanied by pulmonary complications, or followed by a pro- 
tracted cough or obscure fever. The child's general constitution should 
be considered, whether he is delicate, narrow-chested, poorly nourished, 
or anaemic. 

In its symptoms and course it is with simple broncho-pneumonia that 
tuberculous disease is likely to be confounded, hence the important diag- 
nostic points are those which distinguish these two processes from each 
other. The onset of simple pneumonia is usually rapid and often abrupt ; 
tuberculous pneumonia, although it sometimes begins in one of these ways, 
usually develops gradually with constitutional symptoms preceding the local 
ones by several days or even weeks. When tuberculosis develops rapidly, 
the pulmonary symptoms and the physical signs may be identical in the 
two conditions. During the period of acute symptoms there is often 
nothing either in the constitutional or local symptoms to awaken suspi- 
cion. One may be struck with the disproportion between the general 
symptoms — loss of flesh, prostration, and temperature — and the local evi- 
dences of pulmonary disease. When the patient dies in the early acute 
stage the disease is rarely recognised, nor, indeed, can it be diagnosticated 
with certainty. Usually it is not until the time for resolution to occur 
that the course of the disease suggests something diiferent from broncho- 
pneumonia. The question then arises whether we have to deal with a case 
of persistent broncho-pneumonia or with tuberculosis. It should be remem- 
bered that it is not infrequent for simple broncho-pneumonia to resolve 
slowly or to go on to the development of chronic interstitial pneumonia; 
and that local conditions as determined by physical signs, which in adults 
would be regarded as certainly tuberculous, very often in children air 
simple processes. 

Often the course of the disease, after the first acute period has passed, 
furnishes further evidence to clear up the diagnosis ; but not necessarily, 
for in tuberculosis it may be steadily downward, or it may be marked by 
periods of remission and exacerbation, and the same is true of simple pneu- 
monia. Fever is a more constant symptom in tuberculosis, and it is usu- 
ally higher than in persistent broncho-pneumonia; but the exceptions are 
so many and the variations so wide that it is not safe in young children 



1046 THE SPECIFIC INFECTIOUS DISEASES. 

to lay very much stress upon the temperature curve. Anaemia and wast- 
ing are more marked in tuberculosis, and in most cases progressive. A 
copious muco-purulent expectoration is seen almost as frequently in pneu- 
monia as in tuberculosis ; but in neither disease is it common under five 
years. The presence of the bacillus tuberculosis in the sputum is, of 
course, positive evidence of tuberculosis. 

Simple broncho-pneumonia may affect any part of the lungs, but by 
preference the lower lobes posteriorly. The signs of tuberculosis may 
likewise be found anywhere, but most frequently in the anterior part of 
the lung, the mammary region, the axillary margin, or the apex ; if pos- 
terior, the signs are usually at the apex or in the interscapular region. 
From the character of the physical signs, no inference can be drawn unless 
a cavity can be positively made out ; but when the process has advanced 
to that stage, the diagnosis is generally plain from the general symp- 
toms. 

Meningitis developing during a pulmonary disease of doubtful char- 
acter, is generally tuberculous, and its occurrence is usually to be inter- 
preted as establishing the tuberculous nature of the process in the lungs ; 
but this is not invariable, as simple meningitis may follow simple pneu- 
monia, as I have more than once seen proven by autopsy, when both were 
regarded during life as tuberculous. The development of cheesy lymph 
glands in the neck, the groin, or axilla, or the presence of symptoms point- 
ing to enlargement of the bronchial glands, or those of chronic peritonitis 
with or without ascites, or intestinal haemorrhage, — all point strongly to 
tuberculosis. 

If the acute symptoms begin during measles and persist, they may be 
due either to broncho-pneumonia or to tuberculosis. If, however, they be- 
gin insidiously during convalescence from measles, they are very probably 
due to tuberculosis. If the symptoms begin acutely during pertussis, 
they may be due to simple broncho-pneumonia or a tuberculous process ; 
but if they develop gradually and insidiously after pertussis, the disease is 
probably tuberculosis. It should not be forgotten, however, that it is not 
uncommon for simple broncho-pneumonia occurring with pertussis, to 
persist until the attack of pertussis has subsided. I have seen several 
such cases in which consolidation has lasted two or three months and 
yet cleared up entirely. 

If the child was previously healthy and living in good surroundings, 
and if the disease began with acute symptoms, the process is simple pneu- 
monia in nine cases out of ten, no matter how irregular its course, how 
prolonged its duration, or what the physical signs. The physician will 
more frequently be right in his diagnosis if he bases it upon the general 
condition and previous history of the patient, than upon the special symp- 
toms of the disease or the physical signs. Still, after all has been said, 
the diagnosis is in all cases difficult, and in some, particularly the more 



THE CLINICAL FORMS OF TUBERCULOSIS. 1047 

chronic ones, a positive diagnosis is impossible, as no one knows so well as 
he who has an opportunity to follow his cases to autopsy. 

III. Chroxic Phthisis. — This form of tuberculosis, with its chronic 
hectic fever, slow cavity formation, progressive emaciation, night sweats, 
etc., is very rarely seen before the fifth year, and it is not at all frequent 
until the tenth or twelfth year. In its symptoms, course, termination, 
and physical signs, it resembles the same disease in adults, and need not 
be described at length here. 

IV. Tuberculosis of the Bronchial Lymph Nodes (Bronchial 
Glaxds). — This condition is usually associated with some form of pul- 
monary tuberculosis, but it may exist as the most important and some- 
times as the only tuberculous lesion. 

Its symptoms are usually associated with those of pulmonary or gen- 
eral tuberculosis ; but they may occur when the pulmonary changes are 
too few to be recognised either by symptoms or physical signs. From the 
great frequency with which this lesion is found in infants and young chil- 
dren, it might be expected that local symptoms would be common in such 
patients. They are, however, in my experience, quite exceptional. Most 
of the cases in which w T ell-marked symptoms occur are in children over 
two years old, and it is between the third and tenth years that they are 
usually seen. In infancy, although these glands are almost invariably 
affected, death in the great majority of cases occurs from the pulmonary 
disease, before the later changes in the glands have had time to develop. 

General symptoms indicating a tuberculous cachexia may or may not 
precede the local ones. The latter are chiefly mechanical, and depend 
upon the size of the glands and upon their anatomical relations, and very 
little or not at all upon the nature of the changes in them. The most 
important relations, so far as the production of symptoms is concerned, 
are those which they bear to the pneumogastric and recurrent laryngeal 
nerves, the superior vena cava, the trachea, and bronchi ; those less impor- 
tant are to the aorta, pulmonary artery, and oesophagus. 

Pressure upon or irritation of the pneumogastric or recurrent nerves 
produces cough, dyspnoea, and sometimes a change in the voice. The cough 
is hoarse, persistent, and teasing, and frequently occurs in paroxysms which 
in many respects resemble those of pertussis, but it lacks the characteristic 
whoop, and is not accompanied by the expectoration of the mass of tena- 
cious mucus. These paroxysms are severe and often prolonged, but careful 
observation shows distinct differences from those of pertussis, though by 
an unfamiliar ear the two are easily confounded. The dyspnoea, like the 
cough, is paroxysmal, and sometimes strongly resembles ordinary spas- 
modic croup; at other times it is like a severe attack <>l' asthma. Such 
symptoms may come and go, but they are frequently prolonged, and usu- 
ally in the interval between the severe seizures the patienl ie doI wholly 
free from dyspnoea. Although the chief cause of dyspnoea is no doubt 



1048 THE SPECIFIC INFECTIOUS DISEASES. 

nerve irritation, it may be due in part to pressure upon the trachea or one 
of the large bronchi. In dyspnoea from pressure on the trachea the head 
is usually thrown back, and the obstruction is more frequently on expira- 
tion than on inspiration. 

After such symptoms as those mentioned have existed for a few days 
or weeks, and in some cases without any warning, there may occur a sud- 
den attack of asphyxia which may prove fatal. This is generally due to 
ulceration of a caseous gland into the trachea or a large bronchus and the 
escape of a large mass into the air passages, where it produces the same 
effects as any other foreign body. 

Loeb has collected fifteen cases of this description, a summary of 
which gives a good idea of the circumstances under which this accident 
usually occurs : In four cases death took place in the first attack of suffo- 
cation, the only previous symptom having been cough; in three there 
had been a number of milder attacks extending, in two of the cases, over 
a considerable period before the occurrence of the fatal one; in three, 
death occurred in the first attack, in children who had no previous cough 
and who were apparently healthy ; in one, the fatal attack came on during 
pertussis. In the majority of the cases, death followed in from five to ten 
minutes from the first symptom ; in a few the patients lived for an hour. 
In rare cases after ulceration into the trachea, the patient has coughed up 
a large quantity of foul pus, and recovered. 

Pressure upon the superior vena cava is usually associated with spas- 
modic dyspnoea and cough, and causes cyanosis of the face and blueness 
of the lips. There is frequently a puffiness of the face, and there may be 
marked oedema. The coexistence of cyanosis with such oedema, when the 
urine is free from signs of renal disease, should always lead one to suspect 
pressure at the root of the lung. In some rare cases the interference with 
the return circulation has been so marked that meningeal haemorrhage 
has resulted. By a process of ulceration set up by these glands they may 
open, not only into the air passages, but into the pericardium, the oesopha- 
gus, or any of the large vessels. The last mentioned is usually followed 
by instant death. Aldibert reports two cases in which the pulmonary 
artery was opened, death occurring from hsemoptysis, a's there was also a 
communication with one of the large bronchi. In Vogel's case the sub- 
clavian vein was perforated, and death resulted from the entrance of air. 
If ulceration takes place into the surrounding connective tissue, a medias- 
tinal abscess may result, producing any of the pressure symptoms noted 
above, and, in addition, dysphagia from pressure on the oesophagus. Such 
an abscess may point in the supra-sternal notch ; it may open through the 
chest anteriorly between the ribs or at the xiphoid cartilage ; or it may 
burrow along the oesophagus to the peritoneal cavity. As a rule, however, 
patients die of general tuberculosis before the local conditions have ad- 
vanced so far. 



THE CLINICAL FORMS OF TUBERCULOSIS. 1049 

Physical Signs. — In order to produce physical signs, the mass of tuber- 
culous lymph nodes must be large enough to form a mediastinal tumour, 
or so situated as to produce pressure on the trachea or bronchi. As a rule, 
the signs are more characteristic behind than in front. Percussion may 
give dulness anteriorly over the first piece of the sternum or posteriorly 
along one or both sides of the spine from the second to the fifth dorsal 
vertebra; the dulness is rarely complete. Auscultation posteriorly may 
give in the most marked cases amphoric or cavernous breathing, or exag- 
gerated bronchial breathing with prolonged expiration, in those which 
are less pronounced. Large, moist rales are sometimes heard. The aus- 
cultatory signs are so like those of a cavity that it is often difficult to 
believe that a cavity does not exist. The sounds heard appear to be those 
produced in the trachea and bronchi transmitted to the ear with great 
exaggeration by the mass of lymph nodes which surrounds them and 
fills the space between them and the chest wall. When the head is thrown 
back a venous hum may sometimes be heard. If one of the primary bron- 
chi or one of its lobar divisions is compressed, there may be very feeble 
respiration over one lung or one lobe ; if the pressure is sufficient to pre- 
vent the entrance of air, or if one of these large tubes has been plugged 
by a caseous mass, there is an absence of respiratory murmur over a single 
lobe or an entire lung. This sign is of great diagnostic value, but it is 
not often present. 

Diagnosis. — Enlargement of the bronchial glands to a sufficient degree 
to produce symptoms, may occur in syphilis, in Hodgkin's disease, and in 
various forms of malignant disease of the mediastinum. A certain amount 
of swelling is seen in nearly all cases of simple bronchitis or pneumonia, 
especially in those running a subacute or chronic course. Whether this 
simple hyperplasia is ever sufficient to cause such symptoms as those men- 
tioned is exceedingly doubtful. I have myself never known it to pro- 
duce anything more marked than a spasmodic cough. The great infre- 
quency of other forms of enlargement to a sufficient degree to be of 
clinical importance, usually warrants us, from the symptoms mentioned, 
in making the diagnosis of tuberculosis. The development in a child of 
a chronic abscess in the anterior mediastinum, is almost always due to 
tuberculous glands ; and so is one in the posterior mediastinum, provided 
Pott's disease can be excluded. 

The most important points for diagnosis are the association of a spas- 
modic cough with paroxysms of dyspnoea resembling asthma or croup, 
and oedema or congestion of the face. More stress is to be laid upon 
the symptoms than upon the physical signs; the latter are at most only 
confirmatory. The chief difficulty in diagnosis is found in those cases 
which present few or no other signs of tuberculosis, and which come first 
under observation with attacks of dyspnoea or asphyxia resembling laryn- 
geal stenosis. In many such cases tracheotomy has been done without 
77 ' 



1050 THE SPECIFIC INFECTIOUS DISEASES. 

finding any cause for the dyspnoea, the autopsy showing it to be due to 
ulceration and impaction of a caseous gland. 

General Prognosis of Tuberculosis. — The outlook for a young child 
with general or pulmonary tuberculosis is always bad. So long as the 
disease remains confined to the lymph nodes, the child is not usually in 
danger, except from accidents connected with their softening and ulcer- 
ation, which after all are rare. Spontaneous cure may occur in these 
glands in the same way as in others in the body — viz., by encapsula- 
tion, calcification, etc. Such a result is no doubt a very frequent one ; 
exactly how often it occurs it is impossible to say. But when once the 
disease has gained any headway in the lung itself, its steady advance is 
almost certain in a young child. In those who are older and have more 
resistance the chances of an arrest of the process are more favourable. 

If the bacilli have gained entrance into the body in any considerable 
numbers, even though they are shut up in an encapsulated, caseous, 
bronchial gland, the patient is never free from the danger of general 
infection. 

Prophylaxis. — The prevention of tuberculosis must have constant ref- 
erence to its cause. The first essential is the destruction of the tubercle 
bacilli wherever they exist. Since most of the germs existing in the air 
are derived from the sputum of patients affected with pulmonary tuber- 
culosis, it should be insisted upon, everywhere and at all times, that the 
sputum from such cases should be collected in special cups or cloths and 
destroyed either by germicides or by fire. The next point is to avoid 
needless exposure. A tuberculous mother should on no account nurse 
her child nor kiss it upon the mouth. A wet-nurse likewise should be 
free from any tuberculous taint. No nurse or other care-taker should 
ever be employed about children who has, or ever has had, pulmonary 
tuberculosis. It is wise to exclude also those who suffered when children 
from tuberculosis of the bones or the cervical glands, although the dan- 
ger from such persons is extremely slight. If active tuberculosis exists in 
any member of the family, a young child should be kept away from the 
room, and if possible should not reside in the house. On no account 
should infected persons be allowed to kiss children or sleep in the same 
bed with them. The danger from drinking-cups and other dishes should 
not be forgotten. A tuberculous person should either have his special 
dishes, or the utmost care should be taken to boil all those which he has 
used. Cows whose milk is used for children should be under regular veteri- 
nary inspection and should have passed the tuberculin test. In any case 
where the slightest doubt regarding the health of the cows exists, or where 
the source of the milk is unknown, the milk should be heated to a tem- 
perature of 167° F. for twenty minutes. The danger of infection through 
the alimentary canal is very much less than through the respiratory tract, 
and consequently the precautions first mentioned are much more impor- 



THE CLINICAL FORMS OF TUBERCULOSIS. 1051 

tant than those relating to the food, although the latter should on no 
account be neglected. 

In the case of delicate children and those of tuberculous parents or 
with other tuberculous relatives, everything possible should be done to 
fortify them against the disease. They should be kept under more or 
less constant medical supervision as regards their clothing, manner of life, 
etc., and should take cod-liver oil every winter. Every attack of bronchi- 
tis or broncho-pneumonia should be watched with the greatest solicitude. 
Exposure to measles or pertussis should especially be avoided. The coun- 
try rather than the city should be chosen for residence, and the child 
should spend the winter and spring in some warm, dry climate, such 
as that of southern California, or the interior of South Carolina, or 
Lakewood, N. J. Parents should be distinctly taught that watchfulness 
and care do not mean coddling or the keeping of children in the house 
the greater part of the time. Such children should live as much as pos- 
sible in the open air, and every form of sport encouraged which tends to 
keep them there. Overheated houses are one of the most prolific agen- 
cies in perpetuating a delicate condition of health. Plenty of fresh air 
in sleeping apartments should always be insisted upon. All catarrhal 
troubles of the nose and pharynx should receive early and prompt atten- 
tion, especially should hypertrophied tonsils and adenoid growths of the 
pharynx be removed, since these are conditions which form a most 
favourable nidus for the growth of tubercle bacilli. 

Treatment of General and Pulmonary Tuberculosis. — If fresh air and a 
proper climate are necessary for the cure of this disease in adults, they are 
tenfold more necessary in the case of children. Without them there is 
little hope for a child with active pulmonary tuberculosis. Nowhere do 
these cases do so badly as in a hospital located in a city, and no class of 
hospital cases do worse than these. The same regions that are beneficial 
for adult cases usually agree with children, with the exception that the 
latter, as a rule, do better in a warm than in a cold climate. Plenty of 
fresh air and sunshine are essential. A child must be where he can be 
kept in the open air for at least several hours each day, in spite of 
fever, cough, or other acute symptoms. 

For the most acute cases where the children are confined to the bed, 
the largest, best- ventilated, and sunniest room available should be secured, 
and a window should be open the greater part of the time. The general 
management of such cases is the same as for those with acute pneumonia. 

No specific remedy for tuberculosis has as yet stood the test of expe- 
rience. The diet is a matter of the utmost importance Tuberculous 
patients must be fed like most other sick children, care being taken not to 
disturb the digestion by the unnecessary use of drugs. For a staple article 
of diet, milk is the best, and where this is not well borne some of its sub- 
stitutes — kumyss, matzoon, etc.— may be tried. Cream is almost as use- 



1052 THE SPECIFIC INFECTIOUS DISEASES. 

ful as cod-liver oil, and should be given in one form or another whenever 
the child can take it. 

The two drugs which are most useful are creosote and cod-liver oil. 
Creosote may be given both by the stomach and by inhalation, as in cases 
of pneumonia. By the stomach there may be used for older children, the 
shellac-coated pills containing one or two drops of creosote; for those 
who are younger, it may be given in combination with the liquid pepto- 
noids or in an emulsion with cod-liver oil. It is seldom possible to give 
as a single dose more than half a drop to a child of two years ; one of 
five years, two drops may often be given. It should be continued for a 
long period. Cod-liver oil is usually best given in a fresh emulsion, al- 
though some children bear the pure oil better than any other prepara- 
tion. Inunctions of this or other oils is of some value when it is not well 
tolerated by the stomach. Arsenic, iron, and the compound syrup of the 
hypophosphites are all useful as general tonics, but as specifics their ac- 
tion is very questionable. 

When symptoms pointing to tuberculosis of the bronchial glands are 
present, the syrup of the iodide of iron should be used in the same way as 
in disease of the cervical glands. When they ulcerate into the trachea or 
larger bronchi, they generally cause death, no matter what is done. There 
are on record a few cases in which tracheotomy has been of service in this 
condition, but in the great majority it accomplishes nothing. 



CHAPTER XL 
SYPHILIS. 

Syphilis is a communicable disease due to a specific poison. Although 
a certain bacillus, first described by Lustgarten, is quite generally found in 
syphilitic tissue, it is not established that this bacillus is the cause of the 
disease. 

In infancy and childhood both the acquired and the hereditary forms 
of syphilis are seen. 

ACQUIRED SYPHILIS. 

While acquired syphilis is very much less frequent than the hereditary 
variety, it is by no means a rare disease in early life. It is not improbable 
that some of the manifestations of syphilis in later childhood which are 
usually denominated " late hereditary syphilis," are really due to the ac- 
quired form. 

Etiology. — An infant may be infected by its mother during parturi- 
tion ; but this is extremely rare and can take place only when there 
are lesions upon the mother's genitals. Infection is more likely to 



HEREDITARY SYPHILIS. 1053 

be from a mother who contracts syphilis subsequently to the birth of 
the child, and may occur through nursing or accidental contact by 
kissing, etc. In either of these ways children may be infected by wet- 
nurses, or from a venereal sore upon the nipple. Whether syphilis can 
be communicated through the milk when the nipple is perfectly healthy 
and free from fissures, is somewhat doubtful. 

Syphilis may be communicated directly from a syphilitic child to one 
who is healthy by kissing, sexual contact, or indirectly by means of bot- 
tles, spoons, cups, clothing, etc. The latter mode of infection is most 
likely to occur in institutions. Vaccination was formerly a not infre- 
quent mode of communicating syphilis, but since the general introduc- 
tion of bovine virus this is very rarely seen. Oases have been recorded 
by Taylor, Hutchinson, and others where the disease has been conveyed 
by the rite of circumcision, either from the mouth or the instruments of 
the operator. 

The relative frequency of the different sources of infection is shown 
by Fournier's statistics of forty cases : The source of infection was the 
parents in nineteen ; nurses, in eight ; servants, in four ; sexual contact, 
in four ; vaccination, in two ; other children, in two ; a physician, in one. 
The ages at which the disease was acquired in this series of cases were as 
follows : during the first year, nineteen ; during the second year, ten ; 
during the third and fourth years, seven ; from the fifth to the fourteenth 
years, six. 

Symptoms. — The symptoms of acquired syphilis in children are in all 
respects similar to the same disease in the adult. A primary sore is pres- 
ent at the site of infection, which is most frequently the lips, the mouth 
or some part of the face ; very rarely is it seen on the genitals. There 
are very few individual symptoms belonging to hereditary syphilis which 
may not also be present when the disease is acquired. Its course, how- 
ever, is very much milder in the latter and a fatal termination is rare. 
Fournier states that of 'his forty-two cases only one died of marasmus. 
This marked contrast to hereditary syphilis is due chiefly to the fact that 
in the acquired variety the infant is rarely affected during the early 
months of life, a time when hereditary syphilis is so very fatal. 

Tertiary symptoms may appear at any time from three to twenty years 
after the original infection. 

The treatment is the same as in hereditary syphilis. 

HEREDITARY SYPHILIS. 

Etiology.— A child may inherit syphilis from both parents or from 
either separately. If both parents are syphilitic, the child is usually but 
not invariably so. The symptoms, however, are not more severe than 
when the inheritance is from one parent only. The likelihood of trans- 
mission depends upon the stage of the disease in the parents. If both 



1054 THE SPECIFIC INFECTIOUS DISEASES. 

are suffering from secondary symptoms, transmission is almost certain. 
If active treatment has been employed for several months, if the child is 
born at a period when no active symptoms are present, or if the symptoms 
are of a tertiary character, the offspring will probably escape. First-born 
children are more likely to suffer severely from syphilis than the later 
ones, provided infection of the parents has taken place prior to the birth 
of all the children. 

Infection from the father. — Syphilis may be inherited from the father 
alone. In this case the disease is probably communicated directly from 
the semen to the ovum. It is more likely to be transmitted from the 
father than from the mother, as the child is frequently syphilitic when 
the mother has few or no active symptoms. Of twenty cases observed by 
Meyer in which the father alone was syphilitic, the foetus was discharged 
macerated in eleven cases, and nine children were born with congenital 
syphilis, all but one dying soon after birth. It is possible, though rare, 
for the father to convey syphilis when he is free from symptoms, or when 
he is suffering from tertiary symptoms only. 

Infection from the mother. — It is certain that syphilis may be trans- 
mitted when the mother alone is diseased, as is shown by cases where 
women who have acquired syphilis while wet-nursing infected children, 
have subsequently borne syphilitic children, the father remaining healthy. 
If the mother only is syphilitic the probabilities of transmission to the 
child appear to be considerably less than if the father alone is affected. 
If the mother's symptoms are tertiary the child will probably escape. 

Both parents healthy at the time of conception and the mother infected 
during pregnancy. — Under these conditions the child may or may not be 
syphilitic. Transmission to the child is much less likely to occur if the 
mother is infected during the last two months of her pregnancy than 
earlier, although, as Hutchinson's cases conclusively show, there is no cer- 
tainty that the child will escape. Diday states that if the mother is in- 
fected before the fourth week and proper treatment is instituted, the 
child will usually escape on account of the relation of the embryo to the 
maternal circulation during this early period. 

Can a healthy mother bear a syphilitic child? — In 1837 Oolles enun- 
ciated the following proposition, the truth of which has been abundantly 
verified since his time : " A new-born child affected with inherited syphi- 
lis, even although it may have symptoms in the mouth, never causes 
ulceration of the breasts which it sucks if it be the mother who suckles it, 
although continuing capable of infecting a strange nurse." 

Caspary inoculated with syphilis a woman, apparently healthy, who 
had aborted with a syphilitic child ; the result was negative. A similar 
experiment was made by Neumann, with a like result. Vidal reports a 
case of an apparently healthy woman who had a syphilitic child by an 
infected husband ; later, by a second husband who was free from syphilis, 



HEREDITARY SYPHILIS. 1055 

she had a syphilitic child. The conclusion seems irresistible that the car- 
rying of a syphilitic child gives immunity to the mother against the 
disease, and that this immunity is due to the fact that she herself suffers 
from syphilis, or a modification of that disease. According to Hutchinson, 
the modified syphilis acquired by a woman under the circumstances men- 
tioned, bears to syphilis acquired from a chancre a somewhat similar rela- 
tion to that which vaccinia bears to smallpox. The mother under these 
circumstances can not be inoculated, either by her syphilitic nursing-in- 
fant or artificially. 

Lesions. — Death may be due to syphilis, and yet the autopsy may re- 
veal no characteristic anatomical changes, and in fact there may be no 
demonstrable changes in any of the organs. This is sometimes the case 
in children dying from syphilis soon after birth, but it is especially likely 
to be the case with infants who die from, syphilitic marasmus during the 
first few months. Syphilis in these cases acts more as an indirect than as 
a direct cause of death. The most important lesions of hereditary syphilis 
are found in the bones, liver, spleen, and mucous membranes. 

Bones. — In the case of a syphilitic foetus, a stillborn child, or one 
dying soon after birth, the changes in the bones are more uniformly pres- 
ent than are any other lesions. They are in fact rarely wanting, and it is 
by them usually that syphilis is recognised post mortem. These early 
changes were first fully described by "Wegner, and since then have been 
studied by Kassowitz, Taylor, and others. The long bones are principally 
affected, the most important changes being found at the junction of the 
shaft with the epiphyseal cartilage. The lesion is termed an epiphyseal 
osteo-chondritis or acute epiphysitis. There are in the early stage con- 
gestion, swelling, and cell proliferation, which may be followed by separa- 
tion of the epiphysis, suppuration in the neighbouring joint, osteomyelitis, 
and necrosis. These changes, as well as those belonging to late syphilis, 
are more fully considered under Diseases of the Bones (page 851). 

Liver. — This is probably more frequently involved in the footus and 
newly-born infant than any other organ. The syphilitic lesions of the 
liver have been studied very fully by Hudelo.* He describes as present 
in the youngest infants an interstitial hepatitis, a gummatous hepatitis, 
and a combination of the two varieties. 

In the interstitial form, which is most frequent in infancy, there are 
first a congestion and swelling of the organ, with the exudation of leuco- 
cytes in groups. The liver is enlarged, frequently very much so, but pre- 
sents few other gross changes. Later there is increased exudation 
between the liver cells, new connective tissue forms, and atrophy of the 
liver cells takes place, with obliteration of some of the portal and hepatic 
vessels. This process may be diffuse, but it is usually in patches, '.roups 



* Monograph, Paris, 1800. 



1056 THE SPECIFIC INFECTIOUS DISEASES. 

of miliary syphilomata may also be found. If the process is diffuse, the 
liver is large, firm, and of a grayish-yellow colour. If it is localized, the 
affected areas are yellow or gray and the other parts are normal. 

The gummatous form is not frequent in early infancy, but belongs to 
a little later period. In this there may be miliary syphilomata with in- 
terstitial changes, and in addition the formation of small or large gum- 
matous tumours, which may be softened at the centre. They are sur- 
rounded by zones of new connective tissue and the liver cells are atro- 
phied. Amyloid changes may be present. 

In the late form of hereditary syphilis, usually seen in children over 
four or five years old, the liver is rarely affected. Hudelo was able to 
collect but forty-seven such cases. The lesions resemble those of the 
congenital variety. There are found cirrhotic changes, which may be 
diffuse or circumscribed, and gummatous deposits, which vary from a 
minute size to that of a cherry ; there may be amyloid degeneration. 

Spleen. — This is almost invariably enlarged in newly-born children 
with syphilis and in syphilitic foetuses, but nothing characteristic is found 
under the microscope (Birch-Hirschfeld). In older children the enlarge- 
ment of the spleen is apt to be greater than at birth ; the organ may be 
the seat of interstitial changes, and sometimes there may be gummatous 
deposits. These changes are rare in children under two years of age. 

Respiratory system. — In syphilitic infants which are stillborn and in 
those which die soon after birth, there is frequently found in the lungs 
what is known as " white pneumonia." This process consists, according 
to Hillier, in fatty changes in the epithelium of the air vesicles ; with this 
there is associated a certain amount of interstitial pneumonia, which is 
chiefly peri-bronchial. In older cases the interstitial pneumonia is ex- 
tensive, and the lungs may be the seat of gummatous deposits, which 
soften and form small cavities. Accompanying these changes there 
may be bronchiectasis, emphysema, and the usual secondary lesions 
which follow chronic interstitial pneumonia. In syphilitic infants there 
is a strong tendency for all inflammations of the lungs to become chronic. 

The trachea and bronchi are in rare cases the seat of stenosis, which 
results from cicatrization following the softening of gummatous deposits 
in their walls. Lesions of the larynx (page 457) are also infrequent. 
There is usually perichondritis, which more often involves the epiglottis 
than any other part, and sometimes there is the formation of papilloma- 
tous masses ; but ulceration and stenosis are both rare. 

The nasal mucous membrane in the early stage of the disease is very 
constantly the seat of a chronic catarrhal inflammation, which may be 
accompanied by superficial ulceration. In the late cases there is deeper 
ulceration, from the breaking down of gummata, with extension to the 
periosteum, cartilages, and bones, causing perforation of the septum, ne- 
crosis of the bones, etc. 



HEREDITARY SYPHILIS. 105T 

Nervous system. — Syphilitic lesions of the brain and cord are rare in 
children as compared with adults, and they are especially so in infancy. 
The most characteristic cerebral lesion of the newly-born child is hydro- 
cephalus, which may depend upon ependymitis, as in two cases reported 
by D 'Astros, the disease proving fatal in the second month. Syphilitic 
meningitis is exceedingly rare under two years. There is occasionally seen 
in young infants a chronic basilar meningitis (page 721) of syphilitic 
origin. Chronic pachymeningitis associated with gummata has been 
observed as early as the fourth year. Money (London) has reported a case 
with symptoms beginning at eleven months, in which there was chronic 
meningitis with great thickening of the dura mater and cerebral sclerosis. 
A few other cases of a similar nature have been recorded. 

Syphilitic endarteritis of the brain has been observed by Chiari in a 
child only fifteen months old. In this case there was chronic meningitis, 
with endarteritis, thrombosis, and minute spots of yellow softening. Gum- 
mata are very rare before the fourth year, although Barlow's patient with 
multiple gummata at the base, was only fifteen months old. Nearly all 
the syphilitic lesions of the nervous system which are seen in adult life 
have been observed in childhood, although they are infrequent, and in 
young children they are extremely rare. 

Digestive system. — Chronic catarrhal pharyngitis is almost a constant 
symptom of the early cases. Later there is seen superficial or deep 
ulceration of the pharynx, tonsils, or fauces, which may lead to perfora- 
tion of the soft palate or to the formation of condylomata. 

There are no important lesions of the stomach or intestines either 
with early or late syphilis. The rectum is occasionally the seat of ulcera- 
tion, and condylomata may form even in young children. 

Organs of special sense. — Otitis is a frequent accompaniment of the 
early syphilitic pharyngitis. It is very likely to become chronic, and in 
many cases results in a permanent impairment of hearing. Iritis is rela- 
tively rare in children, but it may occur even in intra-uterine life, as 
shown by the presence of adhesions in newly-born children. It is usually 
seen in infants four or five months old, and is always serious. Interstitial 
keratitis occurs frequently as a late manifestation of syphilis. Choroid- 
itis and optic neuritis are both occasionally seen, but they are rare. 

Genito-iirinary organs.— Nearly all these may be affected, but gener- 
ally in the late period of the disease. There may be chronic intersti- 
tial nephritis and more rarely gummatous deposits in the kidney, intersti- 
tial changes in the suprarenal bodies, and orchitis, which usually affects 
the body of the organ, rarely the epididymis; it is generally an inter- 
stitial inflammation, with or without gummatous deposits. 

Among the less frequent visceral lesions may be mentioned, ahsi 
of the thymus, which are usually small and multiple ; enlargement of the 
pancreas, with an increase of connective tissue and glandular atrophy ; and 



1058 THE SPECIFIC INFECTIOUS DISEASES. 

chronic peritonitis. The lesions of the mucous membranes will be con- 
sidered under Symptoms. 

Symptoms. — As the result of syphilis, abortion may take place at any 
period of pregnancy, with the discharge of a dead or macerated foetus, or 
the child may be stillborn at term, or it may be born alive prematurely, 
but with so feeble a vitality that it survives but a few hours. Under 
these circumstances it is often difficult and sometimes impossible to decide 
positively with reference to the existence of syphilis. Maceration of the 
foetus or peeling of the skin is no proof, and even the examination of the 
internal organs may not be conclusive. Lomer examined 43 foetuses, all 
dying before the thirtieth week of pregnancy ; he found the spleen and 
liver enlarged in all, and marked bone changes in 21. Birch- Hirschf eld 
examined 108 newly-born syphilitic infants ; he found the spleen invaria- 
bly enlarged ; typical bone changes were present in 35, but in many cases 
the bones were normal. Mervis, from an examination of 92 syphilitic 
foetuses, states that no eruption upon the skin was found earlier than the 
eighth month. 

Symptoms are present at birth in only a small number of cases. In 
such there is usually a very severe degree of infection, and the infants 
do not often live more than a few days. Upon the skin there may be 
seen an eruption of pustules, papules, or bullae. The bullae are usually 
upon the soles and palms, but may be found upon other parts of the body. 
The name " syphilitic pemphigus" is often given to this condition. Pem- 
phigus in the newly-born, however, is not invariably due to syphilis, but 
may be present in other conditions of low vitality. The bullae are at first 
small, and then coalesce and form larger ones two inches or more in 
diameter. They contain a turbid serum which is sometimes tinged 
with blood, and sometimes yellow from pus. Pustules, when present, are 
usually seen upon the face or scalp. The general appearance of these in- 
fants is wretched in the extreme. The body is wasted, the skin wrinkled, 
and temperature subnormal. The spleen is usually enlarged and often 
the liver also. They suck feebly or not at all, and usually die from inani- 
tion within two weeks. 

In the great majority of cases the infant appears healthy at birth, and 
continues so for a variable time before the manifestation of the character- 
istic symptoms of syphilis. As a rule, the more intense the infection, the 
earlier the symptoms make their appearance. The earliest symptoms are 
generally seen between the second and the sixth weeks. If three months 
pass without evidence of syphilis, the child may be considered safe, 
the exceptions to this rule being very few. Miller * (Moscow) gives the 
following statistics of the time of beginning of symptoms in 1,000 
cases : 

* Jahrbuch f iir Kinderheilkunde, Bd. xxvii, S. 359. 



HEREDITARY SYPHILIS. 1059 

Symptoms appeared during the first week 85 cases. 

•' " second week 138 " 

" " third week 240 " 

" fourth week 177 " 

" fifth week 86 " 

" sixth week 54 " 

" " seventh week 50 " 

" " eighth week 30 " 

After the eighth week 140 " 

Sometimes the constitutional symptoms — wasting, cachexia, etc. — are 
noticed before the local ones, but usually this is not the case. Generally 
the first symptom is the coryza or " snuffles," which resembles an ordinary 
cold in the head, except that it persists. It is accompanied by a hoarse 
cry, indicating that the larynx participates in the catarrhal inflamma- 
tion. Soon the eruption makes its appearance, being generally first seen 
upon the hands and face. Fissures and mucous patches may be seen upon 
the lips, about the anus, etc. With these symptoms there is often slight 
fever, the temperature usually ranging from 99° to 101° F. There may 
also be observed excessive tenderness about the shoulders, elbows, wrists, 
or ankles, due to acute epiphysitis, which may cause the child to cry from 
the slightest amount of handling, and the limbs may be moved so little 
that paralysis is suspected. There may be swelling near any of the joints 
mentioned. 

In a severe case, as these local symptoms develop, the infant's general 
nutrition suffers in a very marked way. It loses steadily in weight ; it 
becomes extremely anaemic ; it whines and frets almost continually, but 
especially at night. The facies is so characteristic as to be almost diag- 
nostic ; the features have a pitiful, drawn expression; and the face is 
wrinkled, giving the infant the look of being very old. The skin has a 
peculiar sallow colour, which has been well described as cafe an lait. The 
symptoms may continue until a condition of extreme marasmus is reached, 
and death occurs from inanition, exhaustion, or from some intercurrent 
affection of the lungs or digestive organs. 

In the milder forms of infection the severe constitutional symptoms 
described are not seen, although the local evidences of disease arc almost 
as marked as in the cases just described. The severity of the symptoms 
is also much modified by treatment, especially when this is begun at an 
early period. 

The most important local symptoms are the coryza, eruption, fissures 
about the mouth and anus, mucous patches, painful swellings at the ex- 
tremities of the long bones, pseudo-paralysis, and onychia. 

Coryza.— In most of the cases this is the first symptom. Beginning 
like an ordinary catarrh, it is distinguished by its severity and its persist- 
ence. There is a copious discharge of mucus and serum, sometimes of 



1060 THE SPECIFIC INFECTIOUS DISEASES. 

muco-pus, and often it is tinged with blood. Thick crusts form, which 
produce the usual symptoms of nasal obstruction ; there is great difficulty 
in nursing ; the infant breathes through the mouth, and the mucous 
membrane of the mouth is dry, causing great discomfort. If untreated, 
the process, which at first involves the mucous membrane only, may extend 
to the submucous tissue, causing ulceration ; but the cartilages and the 
bones of the nasal fossae are not involved till a later period in the disease. 

The nasal catarrh is . associated with more or less laryngitis. This 
causes hoarseness, which at times may amount almost to complete aphonia. 
There are very rarely symptoms of laryngeal stenosis. Dillon Brown has, 
however, reported one case in an infant six weeks old, which recovered 
after intubation. 

Eruption. — This usually occurs after the coryza has lasted about a 
week ; but the two may come at the same time ; or the coryza may be ab- 
sent or so slight that the rash appears to be the first symptom. 

Occasionally there is seen a diffuse blush or roseola, but more frequent- 
ly the eruption is macular, occurring in small, dark-red spots about the 
size of the infant's finger nails, usually circular and often slightly elevated ; 
there is no surrounding inflammation, and rarely any itching. It is usu- 
ally most abundant upon the face, the neck, and the anterior surface 
of the upper and lower extremities, especially the hands and feet, not in- 
frequently extending over the entire body, although it is generally scanty 
over the shoulders and back. When it first appears the colour is bright, 
but gradually becomes of a dusky-red or coppery hue. After a little time 
very fine scales may be seen upon the surface of the red patches. The 
rash comes out slowly, usually requiring from one to three weeks for its 
full development. It fades gradually, leaving a coppery discoloration of 
the skin, which continues for a long time. The duration of the eruption is 
from three to eight weeks. It is shorter if active treatment is employed. 

A papular eruption is rarely seen alone, but is usually associated with 
the macular variety. The papules are of a brownish colour and are hard. 
They are seen most frequently upon the palms and soles, and occurring 
alone they are not characteristic. 

A squamous eruption is frequently seen upon the palms and soles, but 
very rarely elsewhere. In a few cases this scaliness forms the most dis- 
tinctive feature of the cutaneous lesion. 

Fissures and mucous patches. — These are among the most diagnostic 
features of early hereditary syphilis. Fissures are most frequently seen 
on the lips and about the anus, but they may occur about the nostrils and 
occasionally elsewhere. The fissures of the lips are really linear ulcers, 
and are distinguished by their persistence in spite of local treatment. 
They are multiple, deep, painful, and bleed easily. Those at the angle of 
the mouth are especially troublesome. 

Mucous patches may develop from fissures, but more frequently from 



HEREDITARY SYPHILIS. 1061 

papules which are situated in regions where they are exposed to constant 
moisture and friction. They are very common upon the muco-cutaneous 
surfaces and wherever the skin is especially thin. The situations where 
they are most apt to be seen are about the lips, anus, scrotum, and vulva, 
but they may also be found behind the ears, between the toes, in the folds 
of the groin, axillae, or buttocks. In size they vary from an eighth to half 
an inch in diameter ; they are whitish in colour, have rounded borders, 
and are raised rather than excavated ; they never extend deeply. 

With these lesions there may be associated ulcers upon any of the 
mucous membranes, but they are most frequently seen in the mouth or on 
the genitals. The usual seat in the mouth is on the inner surface of the 
lips, the tongue, palate, or fauces ; they are seldom symmetrical, and while 
they extend superficially they are never deep. 

Hemorrhages. — They are generally associated with the lesions of 
the mucous membranes, but sometimes occur without them. .Slight 
bleeding from the nose and lips is not uncommon in ordinary cases of 
syphilis, and all haemorrhages of the newly-born are more frequent in 
syphilitic than in other children. Fischl has reported seven cases of 
multiple haemorrhages in the newly-born, associated with other symptoms 
of congenital syphilis. Mracek noted haemorrhages in thirty-three per 
cent of 160 autopsies on syphilitic stillborn infants or those dying soon 
after birth. Examination of the blood-vessels in some of these cases showed 
infiltration of their walls and narrowing of their lumen. The vascular 
changes were thought to be the cause of the bleeding. 

Kails. — The nails present several peculiarities in syphilitic infants. 
There may be a disease of the matrix resulting in suppuration and exfo- 
liation of the nail— a true onychia. Sometimes the nails are repeatedly 
exfoliated ; at other times they are deeply wrinkled or furrowed ; or the 
dorsum is very much arched, and the nail appears as if it had been 
pinched near the matrix by a pair of forceps. Such nails are often ex- 
panded toward the extremity, and may be decidedly claw-shaped ; they 
are frequently opaque, sometimes having a purplish discoloration; they 
may be short and split into layers. The most characteristic appear- 
ance is the narrow, pinched, claw-shaped nail ; this is an early symptom 
of some diagnostic importance. The hair and eyebrows frequently fall 
out completely. This symptom is not usually present in very early 
infancy. 

Pseudo-paralysis.— This is due to acute epiphysitis, and it may be 
the first symptom of hereditary syphilis to attract attention. It is usu- 
ally noticed when the infant is a few weeks old that one or sometimes 
both arms are not moved, and that the parts are tender and painful 
when handled. The condition is easily confounded with peripheral birth 
palsies. The arm is very frequently held in marked inward rotation 
with the palm looking outward, resembling the position in Erb's palsy ; 



1062 THE SPECIFIC INFECTIOUS DISEASES. 

but careful examination makes it evident that the loss of power is only 
apparent, and that it is due either to the pain which motion produces or 
to epiphyseal separation. A history will usually be obtained that loss of 
power did not exist at birth, but developed subsequently. The electrical 
reactions in these cases are normal, and the rapid improvement under 
mercurial treatment is always diagnostic. The lesions of the viscera in 
early syphilis rarely give rise to any marked symptoms, with the excep- 
tion of the spleen, which is almost invariably found enlarged. 

Late Hereditary Syphilis. — These symptoms may come on at any period 
during childhood or about the time of puberty, but very rarely at a later 
time than this. They are seen both in those who have had the usual 
symptoms of hereditary syphilis in early infancy, and in others where the 
most careful examination into the history fails to disclose any symptoms 
whatever of early syphilis. It is fair to assume in such cases either that 
early symptoms were absent or that they were of trivial importance. It 
is still a matter of dispute whether these late symptoms should be re- 
garded as hereditary, tertiary syphilis, which has not previously given 
signs, or as the late stage of ordinary syphilis in which the early symp- 
toms have been overlooked. It is certain that the symptoms are quite as 
apt to be severe when there is no history of early syphilis as when this has 
been typical. It is quite possible that some of these may be the 
late manifestations of the acquired syphilis not recognised in the early 
stage. 

Late hereditary syphilis shows itself by symptoms which in acquired 
disease would be classed as tertiary. The most characteristic are the affec- 
tions of the teeth, the bones, gummatous deposits in the solid viscera, 
the skin, or mucous membranes, the breaking down of which may lead to 
ulceration. 

Teeth. — There are no peculiarities in the first teeth of syphilitic chil- 
dren except their proneness to early decay. They are rather more likely 
_ to appear early than late. Hutchinson states that 

there occasionally occur abscesses of the gum in 
If young infants, on opening which the crown of 

^f^Mf^M the milk-tooth, usually an upper central incisor, 

Fio. 180.— Typical " Hutch- ma y be removed. 

FoumierT th '" ( ' After The characteristic teeth of syphilis are those 

of the second set. In estimating the diagnostic 
value of these changes, only the upper central incisors are to be relied 
upon ; these are the test teeth. Although changes are frequently seen in 
other teeth, they are not always diagnostic. Typical syphilitic teeth, 
according to Hutchinson, have each a single notch in the centre of the 
edge (Fig. 180). The notch is usually shallow and more or less crescentic 
in shape. The enamel is generally deficient in the centre of the notch, 
and the tooth here is apt to be discoloured. The teeth are dwarfed, 



HEREDITARY SYPHILIS. 



1063 




both as regards their length and width. They often taper regularly from 

the base to the edge, giving rise to the term " screw-driver teeth " (Fig. 

181). The teeth are not so flat as the normal incisors, but somewhat 

rounded and peg-like. They are not 

properly placed, but incline either 

toward or away from each other. 

They are seldom large enough to 

touch the adjacent teeth on both 

sides. 

Although Hutchinson's teeth 
may generally be taken as conclu- 
sive evidence of syphilis, they are 
not invariably so, as Keyes and 
others have shown. It is to be 
remembered in this connection that 
the absence of changes in the teeth 
is of no importance whatever as 
evidence that syphilis is not present. 
Hutchinson states that they are 
wanting in more than half the 
cases. 

Bones. — The form of disease 
which is usually seen at this period 
is an osteo-periostitis, affecting prin- 
cipally the shaft of the long bones and the cranium, 
described (page 853). 

Lymph nodes. — They are much less frequently affected than in adults, 
and in early infancy they are seldom involved. In most cases after the 
first year there may be found a moderate degree of enlargement of the 
post-cervical and epitrochlear glands, swelling of the latter having con- 
siderable diagnostic value. They are situated just above the internal 
condyle of the humerus, and under normal conditions can scarcely be felt. 
In syphilitic children they may be as large as a pea or a small bean ; some- 
times two or three of them can be distinguished. They are so rarely en- 
larged from other constitutional conditions that, provided no local cause 
for the swelling exists, they should always create a suspicion of syphilis. 
The post-cervical glands are frequently affected, but are not so diagnostic. 
The degree of enlargement is rarely great. Occasionally there are seen 
in the neck large masses of swollen lymph glands which resemble tuber- 
culous swellings. They are, however, very rare. 

Special senses. — The most frequent affection of the eye in late syphilis 
is interstitial keratitis, the close connection of which with hereditary syphi- 
lis was first pointed out by Hutchinson. It is usually found associated 
with the typical notched teeth. The diagnostic value of keratitis in syphi- 



Fio. 181. — Syphilitic ".screw-driver teeth." Boy 
nine years old. (Same patient as Fig. 148.) 



It has already been 



1064 THE SPECIFIC INFECTIOUS DISEASES. 

lis is denied by Fournier, who states that, while often syphilitic, it is not 
infrequently due simply to malnutrition. Both eyes are usually affected, 
and in all degrees of severity, from a slight haziness of the cornea to com- 
plete opacity. However, with an early diagnosis and prompt treatment, 
recovery may be expected in most cases. 

Chronic otitis may be a result of the acute process seen in early 
infancy. There is nothing peculiar about the inflammation in these 
cases. A form of deafness occurs in older children, which Hutchinson 
states is almost invariably due to syphilis. Its onset is quite sudden, 
without pain and frequently without discharge. The loss of hearing is 
apt to be permanent, and if it occurs early in childhood it is a cause of 
deaf-mutism. 

Shin. — The most important of the later manifestations of syphilis con- 
sist in the formation of subcutaneous gummata. In the early stage they 
are indurated, elastic, of a grayish colour, with red borders. Under treat- 
ment they disappear quite rapidly by absorption ; but when neglected they 
break down, leaving large deep ulcers. These ulcers are quite charac- 
teristic in appearance, but may be confounded with those due to tubercu- 
losis. The syphilitic ulcer has rounded, thickened, indurated borders, 
and a base which is depressed and has the appearance of being scooped 
out. It is sometimes covered by hard crusts and is surrounded by a red 
areola. It leaves a smooth white scar. The most frequent situation is 
upon the face and upper part of the legs or thighs. Tuberculous ulcers 
have usually soft, flat edges, and do not extend so deeply ; they are more 
irregular in outline ; the cicatrix left is of a purplish colour, which be- 
comes red and slowly fades. Tubercle bacilli may be found. Sometimes 
it is only by the effect of treatment that the diagnosis can be made be- 
tween these two lesions. 

Nose and palate. — Disease of these parts generally begins as the break- 
ing down of gummatous deposits in the mucous membrane. The nose 
may in consequence be the seat of a protracted fetid discharge (ozaena). 
The disease may take on a destructive form of ulceration which is at times 
phagedenic, and may cause rapid destruction of the nasal cartilages and 
bones, perforation of the septum, and occasionally of the floor of the nasal 
fossae. There may be necrosis of the turbinated bones, the vomer, or the 
ethmoid. In the most severe forms the nose may be almost destroyed in 
the course of a few weeks. There may be at the same time deep ulcera- 
tion of the soft palate, leading to perforation. In a young person this is 
almost invariably due to syphilis. In many particulars these ulcerations 
of the nose and palate resemble lupus ; they are distinguished by the 
rapidity of their progress, syphilis often doing as much damage in weeks 
as is done by lupus in years (Hutchinson). 

Other symptoms. — Syphilitic disease of the larynx and bronchi is rare 
in childhood. The former (page 457) may give rise to hoarseness or 



HEREDITARY SYPHILIS. 1065 

aphonia and occasionally to stenosis ; the latter * to a chronic cough and 
asthmatic attacks. There are no characteristic symptoms belonging to 
syphilis of the lungs. The different lesions of the central nervous system 
which may be due to syphilis are all quite rare. The forms have already 
been mentioned, and- their symptomatology is discussed in Diseases of the 
Nervous System. 

The only visceral changes which aid much in diagnosis are those of 
the liver and spleen. The liver is often enlarged, sometimes to a marked 
degree, and occasionally there is ascites, but very seldom jaundice. 

Enlargement of the spleen is a very frequent symptom — in fact, it is 
almost constant during active syphilitic disease. I have several times 
seen it so swollen as to form an abdominal tumour of considerable size. 
In one case, in a boy three years old, the spleen extended five inches below 
the free border of the ribs, quite to the crest of the ileum. It was asso- 
ciated with moderate enlargement of the liver, as is usually the case. 

In addition to the local symptoms of late hereditary syphilis enumer- 
ated, there are others of a general character which are quite as important. 
The body is usually undersized ; the constitution is delicate, and shows 
but little resistance to all forms of disease ; puberty is frequently delayed, 
and the development of the breasts and the genital organs often imper- 
fect ; anaemia is usually present, and the skin has a sallow appearance. 
Mentally, many of these children are somewhat deficient, and in a few 
instances they become idiotic, epileptic, or the subjects of dementia. 

Diagnosis. — The diagnosis of early syphilis in most cases is not diffi- 
cult. The coryza, eruption, labial fissures, mucous patches about the 
anus and genitals, and general cachexia, — all form a picture which it is 
difficult to mistake. In irregular cases the diagnosis is easy just in pro- 
portion to the number of the foregoing symptoms which are present. 
Special care should be taken not to confound the moist papules of simple 
intertrigo upon the buttocks or thighs with those of syphilis. 

In late syphilis the following symptoms are the most reliable for diag- 
nosis : notching of the teeth, falling in of the bridge of the nose, intersti- 
tial keratitis, deafness not traceable to ordinary otitis, enlargement of the 
spleen and epitrochlear glands, ulceration of the palate or nose, the 
sabre-like deformity of the tibia, and nodes upon the tibia or cranium. 

Prognosis. — Generally speaking, the prognosis is much worse in infan- 
tile syphilis than in that of adults. In infancy it is much worse when 
hereditary than when acquired, for the reason that often the child who 
is the subject of hereditary syphilis has been affected by fche poison from 
the very beginning of its existence, and this has modified its entire devel- 
opment. 

* See A. Seibert, M. D., in Archives of Pediatrics, vol. ix, for a report of four cases 
and others collected from literature. 
78 



1066 THE SPECIFIC INFECTIOUS DISEASES. 

The results of 206 syphilitic pregnancies observed by Jullien (Paris) 
were as follows : abortion occurred in 36, stillbirths in 8, and 69 children 
died soon after birth, making a total mortality of 55 per cent ; 50 were 
living and syphilitic ; only 43 living and in good health. Still worse were 
the results in cases observed by Le Pileur : of 154 pregnancies in syphi- 
litic women, there were 120 abortions or stillbirths, 26 children died soon 
after birth, and only, 8 survived. The statistics of the Foundling Asylum 
in Moscow for ten years showed that of 2,038 syphilitic infants the mor- 
tality was over 70 per cent. 

Such a mortality as that indicated in the above statistics is seen only 
in institutions where little or no previous treatment has been employed. 
In private practice certainly nothing approaching it occurs. 

In addition to those who die early as the result of syphilitic infection, 
there must be added many whose constitutions are so impaired by syphilis 
that they fall an easy prey in infancy to pneumonia, diarrhoea or other 
forms of acute disease. The remote effects of syphilis in infancy it is 
hard to estimate ; it exerts a modifying influence upon the constitution in 
childhood and even throughout the life of the individual. 

The prognosis in an individual case depends upon the age at which 
the symptoms develop, the time when treatment is begun, upon its thor- 
oughness, and upon the surroundings and mode of nourishment of the 
child. The outlook is better the longer after birth the first symptoms 
appear; it is also better in infants who are nursed than in those who 
are artificially fed. 

As compared with syphilis of the adult, relapses are rare, and when 
they occur early they are nearly always the result of insufficient treatment. 
If proper early treatment is carried out, the severe late symptoms are rare ; 
patients are usually free from all symptoms until six or seven years old, or 
until near the time of puberty — two periods when they are likely to develop. 

The prognosis is better in the later children of syphilitic parents than 
in the earlier ones, provided infection has preceded the birth of all the 
children. This fact illustrates the general tendency of the syphilitic- 
poison to diminish in virulence as time passes, even without treatment. 
The following instance cited by Bertin well illustrates this point: 

In the first pregnancy, the child died at the sixth month ; in the 
second, at the seventh month ; in the third, at seven and a half months ; 
in the fourth the child was born at term, and lived eighteen days ; in the 
fifth it lived six weeks ; in the sixth the child lived four months, without 
treatment. 

Prophylaxis. — No infected person should be allowed to marry until at 
least two years have passed after the initial sore, steady treatment being 
continued meanwhile ; nor if there are any active symptoms, no matter 
how long a time has elapsed since infection. There is no certainty in 
either case that the child will escape. 



HEREDITARY SYPHILIS. 1067 

The mother should be treated during her pregnancy : (1) if she is 
syphilitic, whether the disease was acquired at the time of concep- 
tion or subsequently; (2) if the father is known to be suffering from 
syphilis, whether the mother has symptoms or not ; (3) if the mother has 
previously shown signs of syphilis, but has had no active symptoms for 
a considerable period. In all these conditions if efficient treatment is 
carried on throughout pregnancy there is a strong probability, but in no 
case a certainty, that the child will escape. The third condition mentioned 
is the one in which treatment is most likely to be neglected, especially if 
the mother has previously borne a child who was not syphilitic. Syphilis, 
however, shows a strong tendency to reappear and become active during 
pregnancy, even though it has been long quiescent, as the following case 
cited by Diday shows : 

A woman who had lost seven children from syphilis was put under 
treatment during the eighth pregnancy; result — child born healthy, and 
continued so. In the ninth pregnancy treatment was continued with a 
like result ; in the tenth pregnancy, no treatment, child syphilitic, dying 
when six months old ; in the eleventh pregnancy, treatment repeated, 
child healthy. 

The danger of infection during labour is slight. If there are upon 
the genitals of the mother either a chancre or syphilitic ulcers, they 
should be thoroughly cauterized before labour. 

As the greatest danger of infecting a child after birth is from its parents 
or a wet-nurse, syphilitic parents should be duly warned of the danger to 
their children, and especially should be cautioned against kissing them 
or sleeping in the same bed with them. The utmost care should be ex- 
ercised to prevent a healthy child from being infected by a syphilitic 
nurse. A nurse should never be accepted without a thorough examina- 
tion, no matter how clear a history may be given. As a syphilitic child 
in the household may be the means of infecting other children, the 
same precautions should be taken as in the case of other contagious 
diseases. The chief danger to other children comes from kissing or 
from using bottles, spoons, or cups which have been infected ; as the 
syphilitic infant is chiefly dangerous on account of the lesions in the 
mouth. Trouble most frequently occurs because of ignorance regard- 
ing the nature of the disease. It is possible for a syphilitic child to nurse 
a healthy woman without communicating syphilis, if the child's mouth 
is treated and the nipple not allowed to become fissured ; but it is an ex- 
periment which should never be tried. 

Treatment. — This should always be begun as soon as the first positive 
symptoms of syphilis appear. Under certain circumstances it may be 
advisable not to wait for symptoms; as, for example, where both parents 
have recently suffered from active symptoms, where previous children 
have died soon after birth, or where, with marked symptoms in the par- 



1068 THE SPECIFIC INFECTIOUS DISEASES. 

ents, the child exhibits the cachexia of syphilis, but no definite local 
symptoms. Such anticipatory treatment need not be continued longer 
than six weeks unless symptoms appear. 

The indirect treatment, designed to reach the child through the 
mother's milk, has fallen into deserved disuse, as it is very uncertain and 
altogether unsatisfactory. 

Mercury is as much a specific for hereditary as for acquired syphilis. 
There are many ways of introducing it into the system : it may be given 
by inunctions, by the mouth, by fumigations, by baths, or hypodermically. 
In most cases inunction is the manner to be preferred in young infants. 
Gr.x of mercurial ointment, diluted with the same amount of vaseline, may 
be rubbed daily into the palms, soles, axillae, or the inner surface of the 
thighs. It is advisable to change the place of inunction from day to day ; 
and if this is done, it is extremely rare that erythema is produced. If for 
any reason inunctions are objectionable, as they may be where the family 
are to be kept in ignorance of the treatment, either the gray powder or the 
bichloride may be given by the mouth. The usual dose of the gray powder 
should be gr.j four times a day; that of the bichloride gr. -gL- four times a 
day, always well diluted. It is rare that larger doses are advisable. When 
the symptoms are urgent, it is often best to substitute calomel for a few 
weeks, as the system can usually be brought more rapidly under the influ- 
ence of mercury by this than by the other preparations mentioned ; gr. ^ 
four times a day is the usual dose required. Other methods of administra- 
tion and other preparations offer no advantages, and have some very ob- 
vious disadvantages. 

The iodide of potassium is to be used, either alone or in combination 
with mercury, whenever such lesions exist as are classed among adults as 
tertiary. This includes all the late manifestations, and the earlier ones 
whenever the bones or viscera are affected. The iodide is usually well 
borne by children, and may be given in almost any desired dosage. In 
infancy it is rare that more than twenty grains daily are required, but 
in older children the necessary amount may be from one to two drachms 
daily. It should always be given largely diluted. 

The duration of mercurial treatment should be at least one year. The 
doses during the last six months may be reduced to one half or one third 
those employed while active symptoms are present. Treatment should be 
longer than a year if symptoms exist. It is often better not to give the 
mercury continuously, but with short periods of intermission. 

The tonic treatment of syphilis is important and should not be neg- 
lected. After specific treatment has been carried on for a time, particu- 
larly if rapidly pushed, the child often becomes anaemic, and suffers greatly 
from general malnutrition. Under such circumstances also it is often 
wise to discontinue mercury altogether for a time, or at least to reduce 
the dose very much, and administer cod-liver oil, iron, wine, and other 



INFLUENZA. 1069 

tonics. Such a change is frequently found to act most beneficially, even 
when lesions are present, which perhaps have been very little or not at all 
affected by the specific remedies employed. A judicious combination of 
specific and tonic treatment is required in every case, whether the reme- 
dies are given simultaneously or alternately. 

Local treatment. — Ulcerative lesions of the skin require cleanliness, 
dusting with calomel or iodoform, or bathing with the black wash. Mu- 
cous patches should be dusted with equal parts of calomel and bismuth. 
Fissures and ulcers of the mucous membranes should be treated by nitrate 
of silver. Phagedenic ulcers of the palate or nose should be cauter- 
ized with nitric acid or the acid nitrate of mercury. The late syphilitic 
ulcers of the skin, due to the breaking down of gummata, should be 
treated with iodoform. 



CHAPTER XII. 

INFLUENZA. 
Synonym : La grippe. 

INFLUENZA is an infectious, communicable disease, which is now gen- 
erally admitted to be due to the bacillus described by Pfeiffer in 1892. 
It is a serious disease in children chiefly from its tendency to complica- 
tions of the upper and lower respiratory tracts, in which respect it closely 
resembles measles. 

Etiology. — Besides the bacillus of Pfeiffer, there are frequently found, 
either associated or separately, in the organs of patients dying from in- 
fluenza, the streptococcus and the diplococcus pneumoniae, for the develop- 
ment of which influenza creates conditions in the highest degree favour- 
able. 

Influenza prevails epidemically, and after epidemics it may be endemic 
for a number of years. In New York the disease has been present, ac- 
cording to Loomis, for at least twenty-five years, although it attracted 
little attention under the name of influenza until the great epidemic 
of 1891. Epidemics prevail chiefly in winter and spring. All ages 
are liable to the disease, infants under one year least so, and in some 
epidemics they may escape altogether. The disease has, however, been 
observed in infants only a few days old, where the mother was Buffering 
from it at the time of delivery. The children most frequently affected 
are those from two to ten years of age. 

The period of incubation is uncertain. It is usually short, being gen- 
erally believed to be from one to seven days. No immunity is afforded 
by one attack ; recurrences and second attacks are not uncommon in the 



1070 THE SPECIFIC INFECTIOUS DISEASES. 

same epidemic, and a patient who has once had influenza seems to be more 
susceptible to the disease in consequence. 

Lesions. — There are no characteristic lesions of influenza ; those which 
are most frequently found are due to catarrhal inflammation of the re- 
spiratory or the digestive tract. In some cases only the upper respiratory 
tract is involved, in which case the disease often spreads to the middle 
ear ; in others, only the lower respiratory tract, this in infancy usually 
spreading rapidly to the lungs, and resulting in broncho-pneumonia. 
Inflammation of the stomach and intestines is much less frequent and, 
as a rule, less severe. This will be considered more fully under Complica- 
tions. 

Symptoms. — The symptoms of influenza are due to the systemic effects 
of a general poison, and to certain local congestions and inflammations 
which are regarded as complications. The two classes of symptoms — the 
general and the local ones — are found in all possible combinations. 

1. The mild, uncomplicated variety. — This lasts from two to five days, 
occasionally a week. The onset is usually abrupt, with chilliness, mus- 
cular pains, and sometimes vomiting. The temperature ranges from 101° 
to 103° F. Even though the fever is not high, the prostration is consider- 
able, and children are often ill enough to remain in bed for several days. 
The usual general symptoms which accompany fever are present. After 
the fever has subsided, the child is left weak and anaemic ; convalescence 
is frequently protracted, and it may be three or four weeks before the 
general health is regained. This is the most common variety seen, the 
essential symptoms being fever and prostration without evidences of local 
inflammation. Often there is in addition a mild coryza at the outset and 
a slight but persistent cough. 

2. Uncomplicated cases of the severe type. — These are not frequent in 
children. They are characterized by high temperature, severe toxic symp- 
toms, and great prostration. They closely resemble cases of pneumonia, 
with the exception that the local symptoms and physical signs in the 
chest are wanting. The onset is usually abrupt with vomiting and head- 
ache, sometimes even with convulsions. The temperature ranges from 
102° to 106*5° F. It more often remains steadily high than fluctuates 
widely. In three cases recently observed I have seen a temperature over 
106° F. in uncomplicated influenza. Marked nervous symptoms are 
usually present ; there may be headache, photophobia, delirium, stupor, 
opisthotonus, and convulsions, — strongly suggesting meningitis, but all 
usually lasting but a day or two. In other cases the tongue has a brown 
coating, the lips are dry and parched, the pulse is weak and rapid, and 
other symptoms of the typhoid condition are present. The duration of 
these severe attacks is from two to five days, where no complication de- 
velops ; a slight fever may, however, continue for a week, or even two 
weeks, gradually subsiding until it reaches the normal. Although the 



INFLUENZA. 1071 

symptoms are very alarming, the attacks are seldom fatal unless pneu- 
monia develops ; but it is a long time before the full effects of such an 
illness have entirely disappeared. 

3. Cases complicated by catarrhal inflammation of the upper respira- 
tory tract. — In this group there are added to the general symptoms of the 
mild uncomplicated variety, a severe coryza, with pharyngitis and often 
stomatitis. The catarrhal symptoms differ from ordinary catarrh of these 
mucous membranes chiefly in severity. They are also likely to be more 
prolonged, and there is a greater tendency to involve the ears and the 
cervical lymph nodes. The usual symptoms of acute rhino-pharyngitis 
are present with its serous, sero-mucous, or muco-purulent discharge. 
The whole pharynx may be the seat of an acute, erythematous blush, or 
the mucous membrane may present a granular or spongy appearance. 
The tonsils are red; occasionally there is follicular tonsillitis; rarely 
membranous patches. The nostrils and upper lip are often excoriated 
from the nasal discharge. The mouth may be the seat of a simple 
or a herpetic stomatitis with superficial ulceration. These catarrhal symp- 
toms are usually severe for three or four days, and gradually subside. In 
infants the temperature may be 104° or 105° F. at the outset, but con- 
tinues high only for a day or two. In older children the temperature 
ranges from 100° to 102° F. 

There are two complications which in infancy are very frequent, — 
otitis and cervical adenitis. Otitis may be either catarrhal or purulent. 
It runs the usual course of otitis following simple catarrhal processes of 
the pharynx, and usually terminates in complete recovery. Exceptionally 
these cases may go on to the development of chronic otitis, or the disease 
may extend to the mastoid cells. In addition to the severe cases, there 
are frequently seen attacks of catarrhal deafness from inflammation of the 
Eustachian tube. Pain in this form is less severe, and may be absent ; 
there is no increased fever. Deafness is the chief symptom, and in most 
cases it disappears spontaneously. 

The adenitis usually involves either the lymph nodes situated below 
the ear and behind the angle of the jaw, or those of the retropharyngeal 
region. The inflammation runs the usual course of such inflammations 
when associated with other diseases. 

4. Cases with broncho-pulmonary complications. — A moderate amount 
of inflammation of the mucous membrane of the larynx, trachea, and large 
bronchi occurs in most of the cases of influenza. In the more severe 
forms, broncho-pneumonia or lobar pneumonia often develops. Some- 
times the pulmonary symptoms do not appear for two or three days, 
or even a week; at other times they are coincident with the development 
of the fever and other constitutional symptoms, and. except for the prev- 
alence of influenza, this would not be considered a factor in these cases. 
A striking feature in these attacks is that the temperature, prostration, 



1072 



THE SPECIFIC INFECTIOUS DISEASES. 



and cerebral symptoms are out of all proportion to the pulmonary signs 
and symptoms. 

The broncho-pneumonia complicating influenza does not differ essen- 
tially from the ordinary types, except that the proportion of cases which 

do not go on to the development of 



DAY 12 3 4 5 



106 

105° 

io± c 

103° 
,102° 
101° 
100° 



is 



l 



^5. 



Fig. 182. — Acute broncho-pneumonia, abor- 
tive type, complicating influenza, in an 
infant six months old. The entire left 
lung posteriorly, was involved. 



areas of consolidation, is larger than 
is seen under most other conditions. 
If lobar pneumonia develops, it 
frequently runs its regular course. 
But besides these two varieties of 
pneumonia, quite a large number of 
cases of an irregular type are seen 
with influenza. These are often of 
short duration, but accompanied by 
extremely high temperature (Fig. 
182). In many cases there is an 
excessive amount of pleurisy, so that 
the process is really a pleuro-pneu- 
monia. In an epidemic occurring 
in the New York Infant Asylum in 
the winter of 1891 and 1892 nearly 
every pneumonia was of this type, 
and in a few weeks there were about 
twenty cases, all of a very severe form. 
This is often followed by empyema. 

5. Cases with g astro-enteric complications. — Vomiting and diarrhoea 
are frequent at the beginning of influenza, and in some cases, especially in 
infants, they may be the predominant symptoms of the attack. The stools 
may be large and fluid, or they may contain mucus and even blood, and 
be passed with pain and tenesmus, — the symptoms being those of an 
acute gastritis or of ileo-colitis of moderate severity. The duration of 
these attacks is usually three or four days, and except in very young or 
delicate children they are rarely fatal. In older children there may be 
initial vomiting, abdominal pain, tympanites, protracted diarrhoea, and 
other symptoms strongly suggestive of typhoid fever. 

6. Influenza in very young infants. — The severe cases in infants un- 
der six months old often present peculiar features. Even though the tem- 
perature is frequently but little above the normal, the prostration is ex- 
treme. The eyes are sunken, the face is pale, there is marked apathy, and 
food is often refused altogether. In other cases there are cyanosis and very 
rapid respiration, indicating acute congestion of the lungs, although no 
abnormal signs are present, except very feeble breathing sounds. Nearly 
always there is a disturbance of digestion, with vomiting and undigested 
stools. Death may occur in two or three days ; sometimes it is postponed 



INFLUENZA. 1073 

for a week, the chief symptoms being gradually increasing prostration, 
and finally collapse, without the development of any marked local evi- 
dences of disease. The system seems in these cases to be overpowered 
by the intensity of the poison. In other cases pneumonia develops, and 
from this death occurs. 

Complications and Sequelae. — The most frequent ones — pneumonia, oti- 
tis, acute adenitis, and gastro-enteritis — have already been considered. 
Cutaneous eruptions are not infrequent, and are often very puzzling. 
There may be a general eruption resembling urticaria, or an erythema 
which sometimes simulates measles, but more frequently scarlet fever. 
These eruptions are irregular in their course and often in their distribu- 
tion, and are not followed by desquamation. In most of the cases with 
high temperature the urine contains albumin, but nephritis is rare ; a few 
examples of it are, however, on record in young children. I have once 
seen pyelitis as a complication. The nervous sequelae of adults — mental 
disturbances, multiple neuritis, etc. — are extremely rare in childhood, 
although they have been observed. One of the most frequent sequelae is 
marked anaemia; this is well-nigh constant after a severe form of the 
disease. Following the disease of the mucous membranes, there may be 
enlarged tonsils, adenoid growths of the pharynx, or chronic enlargement 
of the cervical lymph glands. Attacks of influenza bear the same relation 
to the development of tuberculosis as do those of measles. 

Convalescence after influenza is usually very slow, and it is often many 
months before the full effects of a severe attack have disappeared. A re- 
currence of the symptoms before complete recovery is not uncommon, and 
often second attacks during the same season are seen. For a long time 
the mucous membranes are in an extremely sensitive condition. Relapses 
are often brought about by slight exposure before the symptoms have 
quite disappeared, and I have often seen them occur simply from airing 
an infant in the room. 

Diagnosis. — This is usually easy when the disease is epidemic. The 
sporadic cases often present great difficulties, particularly in the early 
part of the disease. It is often impossible to tell for two or three days 
whether the case is one of pneumonia, malaria, or influenza. In most of 
the severe cases I have seen, pneumonia has been the diagnosis first 
made; it is only by the course of the disease and the absence of any 
physical signs that influenza can be distinguished from pneumonia. 
From malaria, influenza is differentiated by the course of the tempera- 
ture, the absence of enlargement of the spleen and of the plasmodium in 
the blood. The cerebral symptoms may lead to the diagnosis of menin- 
gitis ; the catarrhal symptoms to a suspicion of measles ; and the vomit- 
ing, high temperature, and erythema to a diagnosis of scarlet fever. In 
all these cases it is only the course of the disease which clears up the 
diagnosis. Influenza is characterized most of all by severe constitutional 



1074 THB SPECIFIC INFECTIOUS DISEASES. 

symptoms, without the development of any signs of local disease, while 
it lacks the characteristic symptoms of the other fevers mentioned. 

From ordinary catarrh, influenza differs only in its high communica- 
bility, its severity, and the frequency with which it is complicated by oti- 
tis, adenitis, and pneumonia. Mild cases when not epidemic can not be 
diagnosticated from simple catarrh of the respiratory tract. 

Prognosis. — As a rule, the type of influenza seen in children is milder 
than that which occurs in adults. In the case of children previously 
healthy, few die except from pulmonary complications, while the great 
majority of attacks are mild and recover promptly. In infants the tend- 
ency to pulmonary complications is much greater than in older children. 
Uncomplicated cases are seldom fatal, except in infants under six months 
old ; and even though the temperature is very high and the symptoms 
severe, recovery may usually be predicted so long as there is no evi- 
dence of serious complications. The prognosis of the pneumonia of in- 
fluenza is rather worse than that of simple broncho-pneumonia, and de- 
pends chiefly upon the age of the patients affected. In a word, influenza 
is particularly serious in the very young, or when there are pulmonary 
complications, but rarely otherwise. In infants the constitutional de- 
pression which results may be the beginning of a condition of malnu- 
trition which goes on to the development of marasmus ; or a child falls 
an easy victim to some other form of acute disease. The remote effects 
of influenza may therefore be serious, even though the attack itself is not 
especially severe. 

Treatment. — The communicability of the disease makes it desirable 
that cases of influenza should be isolated whenever this is practicable, and 
particularly that delicate children, or those prone to pulmonary disease, 
should not be exposed to it. 

The disease appears to be self-limited, running its course, when un- 
complicated, in from three to seven days. As there is no specific for it, 
the indications are to sustain the patient, to make him comfortable dur- 
ing the attack, and to prevent so far as possible the occurrence of compli- 
cations. Every child with influenza should be put to bed and kept there 
so long as any elevation of the temperature continues. At the outset the 
bowels should be opened by castor oil or calomel, and means used to 
induce free perspiration, such as the use of hot drinks, the hot pack, or 
small doses of Dover's powder in combination with phenacetine. A very 
high temperature should be relieved by cold sponging or the cold pack, 
precisely as in pneumonia, but large doses of antipyretic drugs are to be 
avoided. The nervous symptoms — restlessness, pain, headache, and other 
disturbances — are best controlled by phenacetine in combination with co- 
deine — e. g., to a child of one year, phenacetine gr. j, codeine gr. ^ every 
three or four hours. Double the dose may be given to a child of four 
years. Alcoholic stimulants are required whenever the pulse shows signs 



MALARIA. 1075 

of weakness, as it does in most of the severe cases, and in most young 
infants. They should be given according to the same rules as in 
pneumonia. Next to alcohol, strychnine is the most valuable heart stim- 
ulant. 

In older children there is a decided advantage in the use of moderately 
large doses of quinine — e. g., gr. ij, four or live times a day, to a child five 
years old ; but in infants this had best be omitted, on account of its tend-, 
ency to upset the stomach. The cough which so often persists after in- 
fluenza is best controlled by cod-liver oil and creosote, used as after acute 
bronchitis. With persistent bronchitis which resists ordinary remedies, a 
patient should be sent to a warm, dry climate. The complications of in- 
fluenza are to be treated as they arise, in the same manner as when they 
occur under other conditions. In all cases careful feeding in accordance 
with the general rules laid down for feeding in acute diseases, good nurs- 
ing, and care to avoid exposure during convalescence, are essentials in 
treatment. One should be particularly anxious about patients who have a 
strong tendency to tuberculosis, and such cases should be watched with 
the greatest solicitude. 

In prolonged or constantly recurring attacks nothing is of much avail 
except a change of air. If this is impossible, a child should be frequently 
removed from one apartment to another, as re-infection often appears to 
take place from the sick-room. 



CHAPTER XIII. 
MALARIA. 

Malaria is a general infectious disease due to the presence in the 
blood of a specific organism known as the plasmodium, or liematozoon 
malaria. It manifests itself in children by the ordinary acute febrile at- 
tacks which are seen in adults and by chronic malarial poisoning. Both 
of these forms may present certain peculiar symptoms dependent upon 
the age of the patient. 

Etiology.— The liematozoon malariae was discovered by Lavaran in 
1881. It is a parasite of the blood and belongs to the group of the proto- 
zoa.* The anaemia of malaria results from the extensive destruction of 
the red corpuscles caused by the growth of the parasite. How it enters 
the blood is as yet undetermined. 

Malaria affects all ages, even the newly-born infant. We must accept 

* For a description of the plasmodium, methods of staining, etc., see James, New 
York Medical Record, 1888; Councilman, The Medical News, January 15, 1887; or 
Thayer and llewetson, Johns Hopkins Hospital Reports, vol. v, 1895. 



1076 THE SPECIFIC INFECTIOUS DISEASES. 

with some allowance the statements made by the older writers upon the sub- 
' ject of intra-uterine infection, but in the following case occurring in the 
practice of my associate, Dr. Crandall, there seems little doubt that the 
disease was contracted in utero : For ten days before delivery the mother 
had suffered from a tertian intermittent of moderate severity. Eighteen 
hours after birth the child was noticed to have cold hands and feet, blue 
lips and nails, and a pinched face. These symptoms lasted about half an 
hour and were followed by a distinct fever. Upon the following day the 
paroxysm was repeated. Examination of the blood of both mother and 
child was made by Dr. Walter James, who found the malarial organisms 
in both cases. 

Malaria is more frequently overlooked in young children than in later 
life, from the fact that its forms are more irregular, and this has led to 
the belief that young children are less liable than adults to the disease. I 
believe, however, the opposite to be the case. In a large number of in- 
stances where families have been exposed to malarial poisoning I have 
noted that the young children were frequently the first to show the 
symptoms of the disease. 

Malaria is an endemic disease prevailing in certain localities. In 
New York it rarely develops except in patients who live along the river 
fronts or in the districts contiguous to Central Park. In many of the 
suburbs malaria is exceedingly prevalent, and in them originate most 
of the cases coming under observation in New York. Malarial attacks 
may be seen at any season, but are more frequent in the fall and spring. 
They are particularly liable to occur when the general health of the 
patient is reduced by some other influence, especially by derangement of 
the digestive organs, and they often follow in the wake of other acute in- 
fectious diseases. The poison of malaria may remain latent in the system 
for an -indefinite time, producing symptoms when the conditions favour- 
able for its development are present. 

Lesions. — Opportunities for a study of the peculiarities of the lesions of 
malaria in children are infrequent, especially in New York, as fatal cases 
are extremely rare. I have myself seen but one. As observed by others, the 
lesions do not differ in any marked way from the adult form of the disease. 
The most important changes are the destruction of the red corpuscles of 
the blood, enlargement, and in chronic cases hyperplasia with pigmenta- 
tion of the spleen ; less frequently pigmentation of the liver, kidneys, 
and brain. Pneumonia and gastro-enteritis are occasional complications. 

Symptoms. — The clinical forms of malarial fever in children from six 
to ten years old, do not differ essentially from the same disease in adults. 
Both intermittent and remittent forms occur, the former being the type 
usually seen. Of the different varieties of intermittent fever,- the quotidian 
(Fig. 183) is the most common, although the tertian (Fig. 184) is fairly 
frequent, but the quartan is extremely rare. The stages of the paroxysm 



MALARIA. 



10' 



are generally well marked. The cold stage begins with a chill or vomiting, 
with headache, lassitude, and general pains. The hot stage is usually char- 
acterized by a higher temperature than in adults, and this is followed by 
the sweating stage, which is generally marked. The paroxysm may be 



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Fig. 183.— Typical malarial temperature, quotidian type, in a boy six years old Each paroxysm 
preceded by a chill. It will be noticed that the temperature rose higher with each succeed- 
ing paroxysm ; x marks the time when quinine was Begun, 

repeated every day or every other day until controlled by quinine, or the 
stages may become less and less distinct as the disease progresses until a 
more or less remittent type of fever develops. Less frequently fche fever 
is remittent from the beginning and the constitutional symptoms are of 
greater severity. In this form there is marked prostration, the tongue 
is thickly coated, there are often tenderness and pain in fche region of fche 
liver, and occasionally there is slight jaundice. 

In infants and very young children the peculiar types of malaria are 
seen. A well-marked intermittent fever with distinct stages is quite ex- 
ceptional, most of the cases assuming more of a remittent type or an irregu- 



1078 



THE SPECIFIC INFECTIOUS DISEASES. 



lar form of intermittent (Fig. 185). The onset is usually abrupt with 
vomiting, a well-marked chill being rare. I have seldom seen a malarial 
chill in a child under five years old. This is replaced in infants by cold 
hands and feet, blue lips and nails, sometimes slight general cyanosis, 
pallor, drowsiness, and prostration. Vomiting was present in two thirds 
of my own cases.* Four times have I seen a malarial attack ushered in 
by convulsions. 

The fever is relatively higher than in adults, rising rapidly to 104° or 
105° F., occasionally to 106° or 106'5° F. This continues from four to 
twelve hours and gradually falls, usually to normal. The other constitu- 



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Fig. 184. — Typical malarial temperature, tertian type, in a boy five years old. Onset with vom- 
iting and drowsiness, but no chill. This was an anticipating 'intermittent, the first parox- 
ysm occurring at 3 p. m., the second at 12 m., the third at 10 a. m. ; x marks the time when 
quinine was begun. 

tional symptoms of the febrile stage are much less severe than in most dis- 
eases with the same elevation of temperature. The sweating stage is only 



* The Symptoms and Diagnosis of Malaria in Children. The American Journal of 
Obstetrics and Diseases of Women and Children, Nos. I to IV, 1883. 



MALARIA. 1079 

slightly marked and is often absent altogether. With the fall in the tem- 
perature there is a gradual subsidence of all the other symptoms of the 
febrile stage. 

After the first paroxysm the patient may be quite well for several 
hours or even for a day, when the second paroxysm occurs. This is gen- 
erally not so well marked as the first one, the third may be even less so, 
and the case may resemble more and more one of continuous fever with 
wide oscillations in the temperature. In some cases it is remittent at first 
and later becomes intermittent, but it is very rare under either circum- 
stances that the temperature does not touch the normal point at some 
time in the twenty-four hours. In infants the quotidian has been in my 
experience very much more frequent than any other type, the tertian being 
rare and the quartan almost unknown. 

Enlargement of the spleen is present in the great majority of cases, and 
usually to a sufficient degree to be readily appreciated by examination. 
The most satisfactory method of examination is by palpation (page 832). 
A spleen which can be easily felt below the ribs (except in the rare cases 
in which the organ is displaced downward by some condition in the thorax) 
is enlarged. When it is not sufficiently enlarged to be readily felt by a 
practised observer under favourable conditions for examination, it is not 
large enough to be of any diagnostic importance. None of the other 
symptoms occurring in malarial fever are characteristic ; they are quite 
similar to those which are seen in almost all febrile attacks. There are 
anorexia, coated tongue, constipation, and restlessness. 

Masked or Irregular Forms of Malaria. — These are quite frequent in 
young children, and are due to the presence of certain special or uncom- 
mon symptoms which may readily lead to a mistake in diagnosis. They 
are more often seen than cases of true malarial cachexia. 

Among the most frequent of the irregular forms are those relating to 
the nervous system. Headache is exceedingly common and is usually 
frontal. When severe and associated with continuous drowsiness, vomit- 
ing, and constipation, it may lead to a strong suspicion of tuberculous 
meningitis. Vertigo is not a frequent symptom, but it is sometimes very 
prominent. Pains in various parts of the body are very common. A sharp 
severe pain at the epigastrium is frequent at the beginning of a paroxysm. 
It is often associated with tenderness, but has no relation to vomiting. 
Less frequently, pain is localized in the region of the spleen or liver. Tri- 
facial neuralgia of malarial origin is rare in childhood. Aching or drag- 
ging pains in the muscles of the lower extremities are frequent symptoms 
during acute attacks, but they are of short duration, disappearing with 
the fever. They are to be distinguished from the acute lancinating pains 
of multiple neuritis, which is occasionally seen as a result of malarial poi- 
soning. I have seen the latter in young children in three cases, and it has 
been observed by others. The pain is accompanied by tenderness of 



1080 



THE SPECIFIC INFECTIOUS DISEASES. 



the muscles and nerve trunks, and by loss of power, which is usually 
partial. 

Spasmodic torticollis (page 683) I have seen in eight cases, in which 
the condition seemed very clearly to depend upon malaria. This was 



day i a 3 4 5 C 7 


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Fig. 185. — An irregular malarial temperature in a child nine months old. The paroxysm on the 
fourth day was accompanied by an attack of acute pulmonary congestion which came near 
being fatal ; x marks the time when quinine was begun. Although the course of the tem- 
perature is irregular, it touched the normal line both on the second and fourth days. 

shown by the fact that the spasm was intermittent, coming on every after- 
noon, but being absent in the morning ; that it was accompanied by a 
slight rise in temperature, and usually by enlargement of the spleen ; and 
that it was immediately controlled by quinine. This combination of symp- 
toms seemed to be conclusive evidence of the malarial origin of the affec- 
tion, although these cases were observed before the time when blood ex- 
aminations were made. 

Accompanying the paroxysm of malaria there is occasionally seen, 
more often in infants than in older children, acute pulmonary conges- 
tion (Fig. 185), which may give rise to obscure and often very alarming 
symptoms. There is an acute onset with vomiting and prostration, high 
temperature, cough, rapid respiration, and often slight cyanosis. On ex- 
amination of the chest there is found feeble or rude respiration over one 
lung, or over both lungs behind, and sometimes coarse moist rales ; these 
signs and symptoms may disappear in the course of a few hours with the 



MALARIA. 1081 

fall in temperature, to return with the next paroxysm, or if quinine is given 
they may disappear entirely.* This group of symptoms has often led to 
the mistaken opinion that the disease was pneumonia, which had been 
aborted by the administration of quinine. 

Subacute or Chronic Forms of Malaria. — The most constant symptoms 
are anaemia, enlargement of the spleen, and slight fever. The anaemia is 
usually marked, often being extreme. The enlargement of the spleen is 
distinct, and easily made out by palpation, and sometimes is very great. 
The fever is often so slight as to be discovered only when the temperature 
is taken five or six times in the twenty-four hours. The other symptoms 
are of a very indefinite character ; there may be slight oedema of the lower 
extremities, general muscular weakness, so that the child is easily fatigued, 
loss of appetite, coated tongue, constipation, headache, muscular pains, and 
often cough from a slight bronchitis. These symptoms may depend upon 
many conditions other than malaria, even when they are seen in a malarial 
district. The only positive evidence of malaria in such cases is the pres- 
ence of the malarial organisms in the blood. Even the swollen spleen, 
anaemia, and slight fever, which are often looked upon as diagnostic, may 
be present in cases of anaemia with which malaria has nothing whatever 
to do. 

Diagnosis. — The positive diagnosis of malaria rests upon the demon- 
stration of the malarial organisms in the blood. They will be found in 
nearly all the cases when examined under favourable conditions, which are : 
(1) that the examination be made by one with considerable experience in 
searching for malarial organisms ; (2) that the examination be thorough ; 



* The following case is a good example of this condition in its more severe form, 
and illustrates the difficulties in the diagnosis of malaria in infancy : A fairly nourished 
child, nine months old, who had been under observation in an institution for two weeks, 
was suddenly taken with vomiting and fever (Fig. 185). A cathartic was followed by 
a large undigested stool, and as the temperature then fell to normal, the attack was 
regarded as one of indigestion. On the third day the temperature was again high and 
accompanied by cough ; coarse rales were found throughout the chest, and line rales 
at the right base^; it was then thought that pneumonia was developing. On the fourth 
day all the symptoms were so much improved that the infant was regarded as conva- 
lescent. At 6 p. m. the temperature was normal, and the infant went to Bleep quietly. 
At 9.30 p.m. he awoke with a temperature of 104°, extreme restlessness, and marked 
dyspnoea. In half an hour his symptoms had increased to a point where he seemed 
likely to die. He became cyanotic, the respirations were of a panting character and 
rose nearly to 100 a minute, "and he coughed with almosl every breath; the pulse was 
scarcely perceptible. The severe symptoms continued for aboul an hour, then passed 
away gradually, and at the end of two and a half hours they had completely disap- 
peared, and the child was in a quiet sleep which continued until morning. Malaria 
was now suspected, and the diagnosis established by the discovery of the Plasmodium 
in the blood. The spleen was at this time much enlarged : the signs in the chesl were 
those only of bronchitis of the large tubes. Quinine was now begun in full d 
and no further malarial manifestations occurred. 
79 



1082 THE SPECIFIC INFECTIOUS DISEASES. 

(3) that it be made during the paroxysm ; and (4) that no quinine shall 
have been previously given. Blood from the spleen is more certain to 
show the organisms than that from the ringer ; and if possible the exami- 
nation should be of fresh blood as well as of dried specimens. While a 
positive result is conclusive, a negative one is not always so because of the 
impossibility of fulfilling all the above conditions. The technique of blood 
examinations is somewhat difficult, and for the great majority of the pro- 
fession a diagnosis must for the present rest upon the other symptoms. 
These, in order of their importance, I place as follows : enlargement of the 
spleen; prompt curability (especially in cases of fever) by quinine; dis- 
tinct periodicity in the symptoms ; and a history of an exposure in a dis- 
trict known to be malarial. Particular importance is to be attached to the 
therapeutic test. Eecent experience emphasizes more and more strongly 
the fact that quinine has very little influence upon fevers which are not 
malarial, and, conversely, that a fever immediately and permanently con- 
trolled by quinine is pretty certain to be malarial. The combination of 
all the above symptoms, even in the absence of an examination of the 
blood, may be regarded as sufficient to establish the diagnosis of malaria. 

The cachexia and course of the temperature in septicaemia, pyaemia, 
broncho-pneumonia, tuberculosis, and empyema, may easily cause them to 
be mistaken for malaria. The fever and recurring chills of pyelitis are 
often attributed to malaria; as are also the heaviness, lethargy, headache, 
coated tongue, and slight fever of chronic intestinal indigestion. Many 
conditions accompanied by an enlarged spleen may be confounded with 
malaria, especially simple anaemia, leucaemia, rickets, and syphilis. While 
malaria may be multiform in its manifestations, the physician can fall 
into no more serious error than to regard all ailments with indefinite 
symptoms as malarial, neglecting careful physical examinations, by which 
means alone accurate diagnosis is reached. 

Prognosis. —Although it is seldom fatal in itself, an attack of malaria 
in an infant may so undermine the constitution that the child may suc- 
cumb to some other acute disease, usually of the lungs or intestines. Cases 
are often difficult to cure while the patient remains in the malarial dis- 
tricts, and while a constant absorption of the poison continues. Under 
other circumstances the prognosis of malaria is good. 

Treatment. — The general treatment is symptomatic, and is to be 
conducted as in all acute febrile diseases. In the cold stage, stimulants 
or a hot bath may be required ; in the hot stage, ice to the head and fre- 
quent sponging. The bowels in all cases should be freely opened, prefer- 
ably by calomel. 

Methods of administration of quinine. — For infants my own prefer- 
ence is to give the bisulphate in an aqueous solution, one grain to the 
teaspoonful, according to the age of the patient. Most infants take 
such a solution with less difficulty and vomit it less frequently than the 



MALARIA. 1083 

combinations with the various vehicles supposed to cover its taste. In the 
event of failure by this method, the same solution may be given per rectum 
through a catheter. It should then be more largely diluted with some 
bland fluid such as milk, and in double the dose. This is necessary, not 
only because absorption is less certain and complete, but also because a 
rectal dose can seldom be repeated of tener than every five or six hours. 
There is sometimes an advantage in giving part of the quinine by the 
mouth and part of it by the rectum ; should both fail it should be given 
hypodermically. For this purpose the bimuriate of quinine and urea, the 
hydrobromate, or the bisulphate may be used. The salt first mentioned 
is to be preferred on account of its greater solubility. The bisulphate is 
the most irritating of these preparations and there usually follows some 
induration at the site of its injection, which may last a long time. This 
method of administration will not often be required, but in certain cases 
it is invaluable. Injections should be made deeply in the buttock or 
thigh ; if the needle is clean no abscess will result. 

For children from two to seven years old the taste of quinine must be 
concealed. An aqueous solution may be mixed with the syrup of sarsa- 
parilla, orange, or verba santa ; or the powdered salt may be given in sus- 
pension in the same vehicle, the mixture being made in both instances just 
before the dose is taken ; otherwise the partial solution of the drug will 
render the wmole dose exceedingly bitter. When the dose required is not 
large, as in the milder cases, the lozenges of the tannate of quinine com- 
bined with chocolate answer the purpose admirably, for these are so 
nearly tasteless that children will take them without difficulty. Each 
lozenge usually contains one grain of the tannate, which is equivalent to 
about one third of a grain of the sulphate of quinine. A similar lozenge 
containing one grain of the sulphate may be made, which is often taken 
by children without the slightest objection. The bisulphate may be given 
in solution by the rectum, or, better, at this age, in the form of supposi- 
tories; but, as in infancy, with urgent symptoms, it is better to resort at 
once to the hypodermic method in case of failure by the stomach. 

For children over seven years old, the same methods of administration 
may usually be employed as in adults. It is always preferable to give 
quinine in solution, or if not so, in capsule, but never in pill form. 

In a case with well-marked paroxysms the quinine should be given in 
the interval, with the largest dose about four hours before the expected 
paroxysm. In infancy this plan is sometimes impracticable, as frequent 
small doses are usually better borne by the stomach than a few large ones. 
If other methods of administration are employed, however, this should 
always be done. I have never succeeded in getting the physiological effects 
of quinine by inunction, though there are good observers who claim this 
result. It is certainly a very uncertain way of introducing quinine into 
the system. 



1084 THE SPECIFIC INFECTIOUS DISEASES. 

Dosage. — Relatively much larger doses of quinine are required for young 
children than for adults. Except for its tendency to disturb the stomach, 
quinine is borne remarkably well by little patients. Generally too small 
doses are given. An infant of a year with a sharp attack of malarial 
fever will usually require from eight to twelve grains of the sulphate 
(ten to fourteen grains of the bisulphate) daily. Occasionally I have 
found it necessary to give double the quantity referred to, and I have seen 
no unpleasant cerebral symptoms. It is useless to expect to control an 
acute attack of malaria by such doses as one grain three or four times a 
day. Children from five to ten years old require almost as large doses as 
do adults. None of the substitutes for quinine are to be relied upon in 
acute cases. 

In chronic cases, arsenic and iron are usually required in combination 
with smaller doses of the quinine than those mentioned. For children 
over seven years old, Warburg's tincture may be employed. In some 
chronic cases a cure can be effected only by a change of climate. 

The marked and irregular manifestations of malaria are to be treated 
in the same manner as cases of malarial fever. 



SECTION X. 
OTHER GENERAL DISEASES. 

CHAPTER I. 
RHEUMATISM. 

The rheumatic diathesis manifests itself in children by quite a differ- 
ent group of symptoms from those seen in adults ; for this reason the 
disease was formerly supposed to be a rare one in early life. It is only 
within recent years that its frequency and its peculiarities have come to 
be appreciated. For our present understanding of the subject we are in- 
debted largely to the work of English physicians, especially Cheadle,* 
who has brought out more fully than anyone else the close connection ex- 
isting between many conditions formerly not regarded as rheumatic. One 
who has in mind only the adult types of articular rheumatism, and regards 
arthritis as a necessary symptom for a diagnosis, will overlook in early life 
many manifestations which are clearly the result of the rheumatic poi- 
son. There is seen at this period a group of clinical phenomena, which 
often occur in combination or in succession, whose association was not 
understood until they were all discovered to be related to rheumatism. 
Sometimes one member of the group and sometimes another is first seen, 
but when one has appeared others are likely soon to follow. 

Rheumatism in childhood, then, is manifested not alone by arthritis 
with acute or subacute symptoms, but by a large number of other condi- 
tions which are not to be regarded in the light of complications, but rather 
as forms of the disease. 

Etiology.— Tt is not in the province of this work to discuss the various 
theories regarding the nature of rheumatism and its exciting cause. The 
drift of medical opinion to-day is strongly toward the view that acute 
rheumatism is an infectious disease, probably of microbic origin, although 
the character of the micro-organism is as yet unknown. The excessive 
formation of acids in the system may be regarded as a result of the infec- 
tion, or possibly as a condition necessary for the activity of the specific 
poison. Under five years of age articular rheumatism is rare, and in in- 
fancy it is extremely rare. I have, however, once seen in a nursing infant, 

* See the Harveian Lectures, 1889. 
1085 



1086 OTHER GENERAL DISEASES. 

a little more than a year old, a typical attack of rheumatic fever with 
multiple joint lesions, and undoubted cases have been reported at as early 
an age as six months. Still, all these are very exceptional, and one should 
be wary of diagnosticating rheumatism during the first, two years of life. 

After the fifth year both the articular and the other manifestations of 
rheumatism become more common, and. occur with increasing frequency 
up to the time of puberty. 

Heredity is a very important etiological factor, and in fully two thirds 
of the cases that have come under my care, a rheumatic family history 
was obtained. Of the other important causes, the most frequent are living 
in damp dwellings, direct exposure to cold and wet, poor hygienic sur- 
roundings, and insufficient food. While seen among all classes, rheuma- 
tism is more common among those who are badly housed. 

Attacks of rheumatism are seen at all seasons, but are much more 
frequent in the spring months. One attack strongly predisposes to a 
second, and in most cases there is a history of a large number of attacks 
of greater or less severity. Among my own patients, girls have been 
affected with greater frequency than boys. 

Symptoms. — The general and articular manifestations. — The clinical 
types of rheumatism in children present very notable contrasts to those 
seen in adults. A typical attack of acute articular rheumatism such as is 
seen in adult life, with a sudden onset, high temperature, severe inflam- 
mation of several joints, profuse acid perspiration, and occasional delir- 
ium, is rarely seen in a child under eight or ten years old. In most of 
the attacks in childhood the onset is not very acute, the temperature is 
but slightly elevated — only 100° or 101-5° P. — the swelling and pain are 
moderate, and the redness is often absent. The number of joints involved 
is generally small, those most frequently affected being the ankles, the 
knees, the small joints of the foot, the wrists, or the elbows. These symp- 
toms are often not severe enough to keep the patient in bed, and only the 
pain in the joints of the lower extremities prevents him from walking. 
The duration of these attacks is from one to three weeka, and in the 
course of a month most of them recover even without treatment. 

Not infrequently the symptoms are limited to a single joint, usually the 
hip, knee, or ankle. Possibly the joints of the upper extremity are affected 
oftener than would appear, but disease here is much more likely to be 
overlooked than when lameness is present. The swelling is moderate and 
may not be evident except on a close examination ; in some cases there is 
none. There is stiffness of the joint, as shown by lameness, and there may 
be so much pain and soreness that the child refuses to walk altogether. 
Muscular spasm about the affected joint is often marked, and may be the 
most striking objective symptom. The tenderness is sometimes local- 
ized, but it may affect the ligaments, tendons, and even the muscles. 
These symptoms may persist for two or three weeks and lead to the 



RHEUMATISM. 1087 

suspicion of incipient tuberculous disease of the joint. Rheumatism is 
distinguished by its more acute onset and usually by the presence of 
slight fever ; some elevation of temperature being the rule, though it is 
not often much over 100° F. A family history of rheumatism, or a his- 
tory of previous similar attacks in the patient affecting the same or other 
joints, or other manifestations of rheumatism, are also of assistance in the 
diagnosis. Occasionally all doubt is removed by the disease extending to 
other joints, or by the development of endocarditis. In some cases the 
symptoms are less in the articulation than in the muscles, and they are 
dismissed as simply " growing pains," having nothing characteristic about 
them except their occurrence in damp weather. 

Cardiac manifestations. — These may occur where the articular symp- 
toms are very mild, and in some cases where they are entirely absent. 
The most frequent is endocarditis. This is much more often seen in the 
acute rheumatism of children than of adults, and probably occurs in the 
majority of all severe cases ; if it does not come in the first attack, it is 
likely to be seen in the later ones. It frequently occurs with a mild rheu- 
matic arthritis, often being unnoticed until valvular disease of considerable 
severity has developed. Sometimes there is only high fever with severe 
constitutional symptoms of an indefinite character, but no arthritis, and 
no suspicion that the attack is rheumatic until endocarditis is discovered. 
Such cases are not infrequent. If the patients are kept under observation, 
articular symptoms are almost certain to develop later, and often there are 
other manifestations of rheumatism, especially chorea. 

Pericarditis is less frequent than endocarditis, and usually occurs in 
children over seven years old. It is often associated with endocarditis. 
The most characteristic form of inflammation in early life is a subacute, 
dry, fibrous form, often resulting in great thickening with extensive adhe- 
sions, and frequently in obliteration of the pericardial sac. When once 
started it shows a strong tendency to recurrence and persistence. 

The heart is so frequently affected in the rheumatism of childhood 
that it should be closely watched whenever articular symptoms are present, 
no matter how mild they may be ; and not only in these cases, but in all 
the conditions hereafter enumerated with which rheumatism is likely to be 
associated. 

Inflammations of other serous mctnhnnn's—tho, pleura, periton»um, 
and pia mater — were much more frequently ascribed to rheumatism in the 
past than now. There is little doubt that on rare occasions any one of 
these may be due to rheumatism. The pleura is most often involved, but 
even this is rare in young children. 

Torticollis when it occurs acutely is frequently rheumatic. This form 
is characterized by its sudden development, continuous spasm, the great 
amount of muscular soreness, the moderate pain, and the fact that it usu- 
ally disappears spontaneously after a few days. It is often seen in con- 



103g OTHER GENERAL DISEASES. 

nection with a rheumatic sore throat. Other manifestations of muscular 
rheumatism are less characteristic and usually affect the muscles of the 
extremities. 

Anaemia is almost invariably seen in rheumatic patients, both during 
and between the attacks. The effect of the rheumatic poison upon the 
blood resembles that of malaria. The presence of anaemia is so evident 
and its degree often so marked, that one may have great difficulty in dis- 
tinguishing cardiac murmurs which are hseniic from those due to endo- 
carditis. 

Chorea. — In the article upon Chorea (page 674) I have already dis- 
cussed the association of that disease with rheumatism and expressed my 
own belief in a very close relationship existing between them. Not very 
infrequently chorea is the first manifestation of the rheumatic diathesis, 
to be followed soon by articular symptoms or by endocarditis without such 
symptoms. In other cases chorea and acute endocarditis occur together 
without articular symptoms, or all three may be associated. Whichever of 
the three conditions is first seen, the physician should always be on the 
lookout for the others. The frequency of rheumatism in choreic patients 
has been variously estimated by different observers ; in my own cases over 
fifty-six per cent gave unmistakable evidences of the rheumatic diathesis. 

Tonsillitis. — Children who are the subjects of frequent attacks of 
acute tonsillitis and pharyngitis should be regarded as possibly rheumatic, 
and should be closely watched for other signs of that disease. A careful 
examination of the family history usually reveals other evidences of rheu- 
matism. Acute tonsillitis often ushers in an attack of rheumatic endo- 
carditis or arthritis, and in one of my own cases a cardiac murmur was 
discovered after an ordinary attack of tonsillitis in a patient whose heart 
previously was normal and who had exhibited no articular symptoms. Of 
the different forms of tonsillitis, quinsy is most closely associated with 
rheumatism. 

Subcutaneous tendinous nodules. — General attention was first drawn 
to these as a manifestation of rheumatism by Barlow and Warner, in 1881, 
who described them as " oval, semi-transparent, fibrous bodies like boiled 
sago grains." They are most frequently found at the back of the elbow, 
over the malleoli, at the margin of the patella ; occasionally on the exten- 
sor tendons of the hands, fingers, or toes, or over the spinous processes of 
the vertebrae or the scapulae. They are composed of fibrous tissue, and 
vary in size from a large pin's head to a small bean, sometimes being as 
large as an almond. The nodules may come in crops, lasting for a few 
weeks and then disappearing, or they may last for months. An erup- 
tion of nodules is usually coincident with other rheumatic manifestations. 
These nodules are better felt than seen, although, as Cheadle observes, 
they are visible if the skin is tightly drawn. They are certainly not com- 
mon in this country ; notwithstanding that I have made it a rule to exam- 



RHEUMATISM. 1089 

ine rheumatic patients for them, I have seen them but seldom, and they 
have been marked in only two or three cases. This, I think, has also 
been the experience of most observers in Xew York. From published 
reports, however, they appear to be much more frequent in England. 
There can be no doubt regarding the connection of these nodules with 
rheumatism. 

Erythema. — The connection between rheumatism and the various 
forms of erythema — marginatum, papulatum, and nodosum — has been 
very clearly shown by Cheadle. Xone of these are frequent conditions in 
childhood, but when seen they should always suggest rheumatism. 

Purpura. — The association of purpura with rheumatism is so often 
seen that there can be little doubt of the close connection between the 
two conditions. Eheumatic purpura, however, is quite distinct from the 
other forms of purpura, and is a much less frequent disease. 

Diagnosis. — In order to recognise rheumatism in a child, one must 
free his mind from preconceived notions of the disease drawn from its 
manifestations in adults, as very few cases correspond to the adult type of 
acute rheumatism. In early life the disease is recognised not by any one 
or two special symptoms, but by the association or combination of a num- 
ber of conditions which may appear unrelated. In determining whether 
or not anv given set of symptoms is due to rheumatism, one should con- 
sider : (1) The family history, since in early life heredity is so important 
an etiological factor; (2) the previous history of the patient, not only as 
regards articular pains and swelling, the slight joint-stiffness without 
swelling, the indefinite wandering pains of damp weather, and the so-called 
growing pains, but also the previous existence of chorea, frequent attacks 
of tonsillitis, torticollis, or erythema ; (3) the examination of the patient, 
which should include a careful search for tendinous nodules, as well as a 
thorough examination of the heart for signs of endocarditis or pericar- 
ditis, and, in cases which are at all acute, the temperature. In doubtful 
cases with mon-articular symptoms much importance is to be attached 
to the presence of slight fever, the abrupt onset, and tenderness of the 
neighbouring muscles and tendons, — all occurring without a history of 
traumatism. Rheumatism is more often overlooked than confounded 
with other diseases ; although in childhood multiple neuritis and tubercu- 
lous and syphilitic bone disease are often mistaken for it, and in infancy 
the same is true of scurvy. The extreme infrequency of rheumatism 
during the first two years of life should always make one skeptical regard- 
ing it. In an infant, when the symptoms arc confined to the legs and 
are not accompanied by fever, they are almost certain to be due to scurvy 
even though the gums are normal and ecchymoses have not yet appeared 
(page 213). 

Prognosis. — Rheumatism in a child is in itself seldom if ever danger- 
ous to life. In the great majority of cases the articular symptoms soon 



1090 OTHER GENERAL DISEASES. 

disappear, even without special treatment. The danger from the disease 
consists in its cardiac complications. One attack of rheumatism is almost 
certain to be followed by others, and when once the heart has been af- 
fected its lesions are likely to increase with each recurrence of the disease. 

Treatment. — Rheumatism in children derives its chief importance from 
its relation to cardiac disease. Cardiac complications are so frequent and 
so serious that everything possible should be done to avert rheumatism 
from those who by inheritance are especially predisposed to it, to prevent 
its recurrence in a child who has once had the disease, and during an attack 
to prevent the heart from being involved. The relation of diet to rheuma- 
tism is very imperfectly understood ; but it is certainly a fact that rheu- 
matic children do much better upon a diet composed largely of nitroge- 
nous food, where starches are restricted in amount, than the reverse. Milk 
should be freely given in all cases. The underclothing should be of flan- 
nel during the entire year, in summer the lightest weight being worn. 
The feet should be carefully protected, and exposure in damp weather 
avoided. In-door occupations should be chosen for rheumatic boys. 

The tendency to recurrence is so strong in this disease that a child of 
rheumatic antecedents, who has shown in the various ways mentioned a 
marked predisposition to rheumatism, and Avho has had an attack, even 
though a mild one, should, if possible, spend the winter and spring in 
some warm, dry climate, or even remain there permanently. Otherwise in 
most such children, it is only a question of time when, with the repeated 
attacks, the heart will become involved. 

To avert the danger of cardiac complications during an attack of rheu- 
matism, or to limit their extent, there are two things which should invari- 
ably be insisted on : first, to confine to the house and in a warm room every 
child with rheumatic pains, no matter how mild ; secondly, if fever is also 
present, to keep the child in bed while it continues, even though it may 
never be above 100° F. Absolute rest and the equable temperature thus 
secured are unquestionably of more importance than anything else in pro- 
tecting the heart during a rheumatic attack. With these precautions must 
be combined an early diagnosis. In very many, perhaps in most cases, the 
harm is done before the true nature of the disease is suspected, the symp- 
toms being dismissed as of slight importance because the articular mani- 
festations are not very severe. Children who have once had rheumatism 
should be closely watched during chorea and other diseases related to 
rheumatism, the heart should be frequently examined, and the physician 
should be on the alert for the first articular symptoms. 

Aside from the measures just mentioned, the treatment of rheumatism 
in childhood is to be conducted very much like that of adult life. In the 
most acute attacks either salicylate of soda, oil of wintergreen, or salicin 
should be given ; as the majority of cases are not very acute, marked im- 
provement is by no means always obtained by these drugs. Alkalies 



DIABETES MELLITUS. 1091 

should be given in all cases, but particularly in those in which there is 
hyperacidity of the urine. Either the acetate or citrate of potassium or 
the bicarbonate of sodium may be used, a sufficient quantity being admin- 
istered to render the urine alkaline. 

Quite as important as these drugs is the use of general tonics, particu- 
larly iron and cod-liver oil. These should be given not only between 
attacks to fortify patients against their recurrence, but also in subacute 
cases which are sometimes influenced very little or not at all either by 
salicylates or alkalies. 



CHAPTER II. 
DIABETES MELLITUS. 

Ix this chapter will be attempted only a description of the peculiar 
features which diabetes presents when affecting young patients. It is a 
very infrequent disease in children. Of 1,360 cases of diabetes collected 
by Pavy, only eight were under ten years of age. In a series of TOO cases 
collected by Prout, only one case was under ten years. In a series of 380 
cases collected by Meyer, only one case was under ten years of age. 

Etiology. — Stern, in a series of 117 collected cases of diabetes in chil- 
dren, states that 47 were females and 31 males, the sex in the other cases 
not being given. Although extremely rare, cases have been observed 
during the first two years, and even during the first year of life. Sta- 
tistics on this point are not altogether trustworthy, since some cases of 
temporary glycosuria have certainly been included. 

Among the etiological factors, heredity is one of the most important. 
Pavy reports the case of a child dying of diabetes at two years in whose 
family the disease had existed for three generations. Inherited gout, 
insanity, and nervous diseases generally, may be looked upon as factors in 
the production of diabetes. Several of the cases reported in children 
have been preceded by injuries received upon the head. In a few cases 
the disease has followed the consumption of large quantities of sugar for 
a long time. In very many cases no adequate cause can be found. 

Symptoms.— The most important early symptoms are thirst, polyuria, 
and wasting; their development is often quite rapid. The thirst La in- 
tense, often leading children to drink four or five pints of fluid a day. 
The amount of urine passed varies from one to eighl quarts daily. 'The 
specific gravity is from 1,026 to 1,040, and the amount of sugar is from 
five to ten per cent, rarely more. Albumin is not infrequently present. 
Incontinence of urine is an important symptom, and often one of the 
earliest to be noticed. The wasting is usually quite rapid, so that a child 
may lose as much as six or eight pounds in a month. It is generally ac- 



1Q92 OTHER GENERAL DISEASES. 

companied by anaemia. The appetite may be poor ; at times, however, it 
is voracious. Other symptoms of less importance are a dry mouth, scanty 
perspiration, irregular sleep, occasional epistaxis, furuncles and abscesses, 
decayed teeth, and genital irritation. 

The course of the disease is much more rapid in children than in 
adults, and, as a rule, the younger the child the more rapid its progress. 
The majority of cases prove fatal in from two to four months from the 
time the symptoms are sufficiently marked to make the diagnosis possible. 
Very few last more than six months ; occasionally, however, one of the 
milder type may be prolonged from one to two years. 

The progress of the disease is marked by continuous wasting, which 
may result in a marked degree of marasmus, and prove fatal. Some are 
carried off by intercurrent pneumonia or tuberculosis, but the majority 
die comatose. When coma develops, the case may be considered hopeless, 
and death is likely to be postponed but a few days. The cause of diabetic 
coma has not yet been satisfactorily explained, but it is usually believed to 
be due to acetonemia. 

Diagnosis. — Diabetes is apt to be overlooked, because of the common 
neglect of urinary examinations in children. The prominent symptoms — 
thirst, polyuria, and wasting — when associated, should always attract at- 
tention. Incontinence of urine, accompanied by marked wasting, is always 
suspicious. In some cases genital irritation may be the most prominent 
early symptom. A positive diagnosis is made only by an examination of 
the urine. 

Prognosis. — In few diseases is the prognosis so bad as in diabetes in 
children. So high an authority as Senator declares that diabetes in chil- 
dren is hopeless and all treatment is useless. From a study of seventy- 
seven cases, Stern reaches the same conclusion. There are, however, cases 
on record in which recovery is believed to have taken place, even when the 
amount of sugar passed was large. 

Treatment. — The indications for treatment are the same in children 
as in adults : first, diet ; secondly, stimulants ; thirdly, general hygienic 
measures ; and, finally, the use of drugs, of which at the present time the 
favourites are codeine, salicylate of soda, and the bromide of arsenic. 



INDEX. 



Abdomen, examination of, 37; growth of, 24; 
in rickets, 229. 

Abscess, alveolar, 243 ; cerebral, 725 ; etiology, 
725 ; lesions, 725 ; symptoms, 726 ; diagnosis, 
727 ; from meningitis, 727 ; prognosis, 727 ; 
treatment, 727 ; cerebral, in acute otitis, 883 ; 
ischio-rectal, 407; mammary, 115; hepatic, 
410; peritoneal, 417 ; peritonsillar, 270; peri- 
typhlitic (see Appendicitis), 389 ; psoas, in 
spinal caries, 842 ; retro-cesophageal, 276 ; 
etiology, 276 ; symptoms, 277 ; diagnosis, 277 ; 
prognosis, 278; treatment, 278; retro-ceso- 
phageal, in Pott's disease, 262, 842; retro- 
pharyngeal, in Pott's disease, 842; retro- 
pharyngeal, of infancy, 258 ; etiology, 259 ; 
symptoms, 259 ; prognosis, 260 ; diagnosis, 
261 ; treatment, 261 ; subphrenic, 427. 

Abscesses, multiple, in malignant endocarditis, 
578 ; multiple, in newly-born, 83. 

Acetonemia in diabetes mellitus, 1092. 

Acetonuria, 603. 

Acid, hydrochloric, increased by lavage, 299 ; 
hydrochloric, in gastro-enteric infection, 330 ; 
hydrochloric, in stomach digestion, 280 ; lac- 
tic, in stomach digestion, 280. 

Adenie (see Hodgkin's Disease), 831. 

Adenitis, acute non-suppurative, 822; acute 
simple, with otitis media, 821 ; acute suppu- 
rative, axillary, 821; acute suppurative, cer- 
vical, 821 ; acute suppurative, inguinal, 821 ; 
cervical, in diphtheria, 9G9 ; in influenza, 
1071 ; in measles, 921 ; retro-cesophageal, 276 ; 
retro-pharyngeal, 258 ; simple acute, 819 ; 
etiology, 820 ; lesions, 820 ; symptoms, 820 ; 
diagnosis, 822 ; treatment, 822 ; simple chron- 
ic, 822; syphilitic, 823; tuberculous, 824; 
etiology, 824 ; lesions, 825 ; symptoms, 826 ; 
prognosis, 829; diagnosis, 829; treatment, 
829 ; treatment, surgical, 830. 

Adenoid vegetations of pharynx, 263, 431 ; 
etiology, 263 ; symptoms, 268 ; diagnosis, 
266; treatment, 266 ; asthma from, 474; cause 



of acute otitis, 885; causing acute nasal ca- 
tarrh, 430; chronic laryngitis with, 456; in 
rickets, 230 ; removal advised in tuberculous 
adenitis, 830 ; with adenitis, 823. 

Adenoma of umbilicus, 112. 

Agenesis, cortical, 741. 

Airing, when allowed out of doors, 8. 

Air-space required by infants, 10. 

Alalia, 692. 

Albinism, stigma of degeneration, 757. 

Albumin water, preparation of, 292. 

Albuminuria, functional or cyclic, 596; in 
chronic cardiac disease, 582; in chronic ne- 
phritis, 621; in influenza, 1073; in measles, 
921 ; in pertussis, 942 ; in scarlet fever, 901 ; 
in typhoid fever, 1013. 

Alcohol, as stimulant, 49 ; as tonic, 50 ; effect 
on breast milk, 164 ; use of, in diet of nurse, 
135. 

Amyloid degeneration, in chronic bone disease, 
838 ; of the intestines, 360 ; of the liver, 360 ; 
of the spleen, 360. 

Anaemia, cardiac murmurs in, 589 ; following 
diphtheria, 972; pernicious, 803; etiology, 
803 ; lesions, 804 ; symptoms, 804 ; blood, 
804 ; diagnosis, 804 ; treatment, 805 ; pseudo- 
leucaemic, of infancy, 801 ; etiology, 801 ; 
lesions, 801; symptoms, 802; blood, 802; 
prognosis, 803 ; diagnosis, son j treatment, 
805; simple, 797; etiology, ^'-'T : Bymptoms, 
798; prognosis, 798; treatment, 805; splenic 
(see A. Simple), 798 ; with adenoids, 265 ; in 
malaria, 1075; in malnutrition, 19S; in ma- 
rasmus, 207; in rheumatism, 1088; in rickets, 
230; in scurvy, 214; in tuberculosis, 1042; 
preceding tuberculosis, 1035. 

Anaesthesia, partial, in multiple neuritis. 7--. 

Anasarca, general, in acute diffuse nephritis, 
616; in chronic cardiac disease, 582. 

Aneurism, 591. 

Angina, catarrhal, in u. JO; in scarlet 

fever, 



1093 



1094: 



INDEX. 



Anglo-Swiss food, 156. 

Ankle, enlarged epiphyses in rickets, 228. 

Anodynes, 51. 

Anorexia, hysterical, 688. 

Antipyrine, in chorea, 679 ; in catarrhal croup, 
441 ; in pertussis, 946 ; scarlatiniform rash 
from, 905. 

Antipyretic drugs, 48. 

Antipyretics, 46 ; in acute broncho-pneumonia, 
511. 

Antitoxine, in the treatment ot tetanus, 90 ; re- 
sults without, in pseudo-membranous laryn- 
gitis, 449 ; with, 998 (see Diphtheria Anti- 
toxine) ; streptococcus, 1007. 

Anuria, 604. 

Anus, fissure of the, 404 ; imperforate, 116. 

Aorta, abnormal origin of, 564 ; aneurism of, 
592; atheroma of, 592 ; congenital narrowing 
of, in chlorosis, 800 ; hypoplasia of, 591 ; 
thrombosis of, 593. 

Aortic insufficiency, 585 ; stenosis, 584. 

Aphasia, functional, 692 ; in acquired cerebral 
paralysis, 747 ; in typhoid fever, 1013 ; motor, 
in cerebral tumour, 730, 731 . 

Aphonia, hysterical, 687 ; in diphtheritic pa- 
ralysis, 791. 

Appendicitis, 389 ; etiology, 389 ; lesions, 389 ; 
catarrhal form, 389 ; ulcerative or perforative 
form, 390 ; symptoms, 391 ; catarrhal form, 391; 
perforative form, 391 ; prognosis, 393 ; diag- 
nosis, 393 ; from colic, 393 ; from acute in- 
digestion, 393 ; from intussusception, 394 ; 
from psoitis, 394 ; treatment, 394. 

Arm, paralysis of, at birth, 110. 

Arnold sterilizer, 144. 

Arsenic, as a tonic, 50 ; dosage in chorea, 679. 

Arteries, hypogastric, in foetal circulation, 558; 
hypoplasia of, 591 ; umbilical, in foetal circu- 
lation, 558. 

Arthritis, acute, of infants, 835 ; etiology, 835 ; 
symptoms, 835 ; diagnosis, 836 ; treatment, 
836 ; acute suppurative, syphilitic, 852 ; gon- 
orrhoea!, 638, 642 ; rheumatic, 1086. 

Arthrogryposis (see Tetany), 668. 

Artificial feeding, circumstances favouring, 158 ; 
versus wet-nursing, 158. 

Ascaris lumbricoides (see Worms, Intestinal), 
398. 

Ascites, 426 ; causes, 426 ; detection of, 426 ; 
chylous, 426 ; in acute diffuse nephritis, 616 ; 
in cirrhosis of liver, 412; rare with amyloid 
liver, 413; with chronic peritonitis, 419; 
with tuberculosis of the peritonaeum, 421. 

Asphyxia, death from, in young children, 44 ; 
from overlying, 42 ; from aspiration of food, 
43; from enlarged thymus, 43; in convul- 
sions, 656 ; in retro-pharyngeal abscess, 260 ; 



in the newly-born, 67 ; etiology, 67 ; lesions, 
67 ; symptoms, 68 ; diagnosis, 69 ; prognosis, 
69 ; treatment, 69 ; from tuberculous bronchial 
lymph nodes, 1048; methods of resuscitation, 
71 ; sudden, from tongue-swallowing, 242 ; 
sudden, in retro-oesophageal abscess, 277. 

Aspiration of chest in empyema, 553. 

Asthma, 473; etiology, 474; symptoms, 474; 
symptoms of attacks resembling capillary 
bronchitis, 475 ; symptoms following attacks 
of bronchitis, 475 ; symptoms of hay fever, 
475 ; symptoms of adult type, 476 ; diagnosis, 
476 ; prognosis, 476 ; treatment, 476 ; catar- 
rhal, 475; in adenoids, 265 ; long uvula, cause 
of, 258 ; simulated by tuberculous bronchial 
glands, 1047. 

Astigmatism, stigma of degeneration, 758. 

Ataxia, Friedreich's, 780 ; in multiple neuritis, 
788. 

Atelectasis, acquired, 539; from compression, 
539 ; from obstruction, 540 ; in delicate in- 
fants, 540; causing sudden death, 43; con- 
genital, 72; lesions, 72; symptoms, 73 ; diag- 
nosis, 74 ; treatment, 75 ; in marasmus, 205. 

Atheroma, 591. 

Athetoid movements, 680 ; in acquired cerebral 
paralysis, 748 ; in birth paralysis, 745. 

Athetosis, 680. 

Athrepsia (see Marasmus), 204. 

Atomizer, 55 ; steam, 59. 

Atresia ani, 307. 

Atrophy, infantile (see Marasmus), 204 ; mus- 
cular, facial type, 785 ; in multiple neuritis, 
788; juvenile form, 785; progressive mus- 
cular, hand type, 782 ; peroneal type, 783. 

Atropine, hypodermatically in cholera infan- 
tum, 336. i 

Aura of epilepsy, 662. 

Autopsies, principal lesions found in, 39. 

Babcock's centrifugal machine, 133, 140. 

Bacillus, of diphtheria, 951 ; distribution in the 
body, 955 ; in milk, 145 ; in healthy throats, 
978 ; in laryngeal diphtheria, 445 ; non- viru- 
lent, 978 ; of Eberth, in typhoid fever, 1008 ; 
of Friedlander, in acute broncho-pneumonia, 
482 ; Klebs-Loeffler (see B. Diphtheria), 
951 ; of Pfeiffer, in influenza, 1069 ; pseudo- 
diphtheria, 978; of tuberculosis, 1016; in 
acute broncho-pneumonia, 483 ; in empyema, 
549 ; paths of infection, 1020. 

Backwardness, 692. 

Bacteria, in etiology of diarrhoea, 318 ; in hu- 
man milk, 137 ; intestinal, 282. 

Bacterium coli commune, 282 ; in appendicitis, 
389 ; in milk, 145 ; in peritonitis, 416. 

Bacterium lactis aerogenes, 282. 



INDEX. 



1095 



Balanitis, 638. 

Band, abdominal, 1, 3. 

Barley water, directions for making, 154 ; use 
during first year, 180. 

Barlow's disease (see Scorbutus), 210. 

Bath, at birth, 1, 2 ; cold, 48 ; in acute broncho- 
pneumonia, 511 ; in asphyxia of newly -born, 
70 ; hot, 54 ; hot air, 54 ; vapour, 54 ; mus- 
tard, 54 ; bran, 55 ; tepid, 55 ; shower, 55 ; 
cold sponge, 55 ; hot, in asphyxia of newly- 
born, 70 ; in typhoid fever, 1016. 

Bed-wetting, 644. 

Beef, broth, 154; extracts, 153 ; juice, expressed, 
153 ; juice, without cooking, 153 ; prepara- 
tions of, 153 ; raw scraped, 154. 

Belladonna, 51 ; elimination of, in milk, 136 ; 
scarlatiniform rash, 905. 

Bile-ducts, congenital malformations of, 75. 

Bile, physiological action of, 281. 

Birth paralyses, 105 ; cerebral, 105 ; spinal, 105 ; 
peripheral, 105. 

Bladder, contraction of, causing enuresis, 645 ; 
control acquired, 645 ; exstrophy of, 637 ; 
haemorrhage from, in newly-born, 104; stone 
in, 650 ; training to control, 4. 

Bleeders, 808. 

Blindness, hysterical, 686 ; stigma of degenera- 
tion, 758 ; transient, in pertussis, 942. 

Blisters, 52. 

Blood, circulation of, in early life, 558 ; cor- 
puscles, red, 795 ; corpuscles, white, 796 ; dis- 
eases of, 795 ; haemoglobin, 795 ; in chlorosis, 
800 ; in diphtheria, 962 ; in leucaemia, 807 ; 
in pernicious anaemia, 804 ; in pseudo-leucae- 
mic anaemia, 802; in simple anaemia, 799; 
leucocytes of, varieties, 796 ; plasmodium 
malariae in, 1075 ; specific gravity, 795. 

Blood-serum, Loeffler's, 952. 

Blood-shadows, 797. 

Blood-vessels, diseases of, 591 ; aneurism, 591 ; 
arterial hypoplasia, 591 ; atheroma, 591 ; em- 
bolism, 592 ; thrombosis, 592. 

Boat-belly in tuberculous meningitis, 718. 

Boil (see Fubonoulosis), 871. 

Bone-marrow in leucaemia, 806. 

Bones, discuses of, 835; in hereditary syphilis, 
1055; in late syphilis, 1063; lesions of, in 
rickets, 218 ; microscopical changes of, in 
rickets, 219; syphilitic diseases of, 851; tu- 
berculous diseases of, 836 ; etiology, 837 ; le- 
sions, 837. 

Bothriocephaluslatus, 397. 

Bottles, nursing, choice and care of, 178. 

Bowels, haemorrhages from (see Hemorrhage, 
Intestinal) ; movements of, irregularity in 
times for, 374; training to control move- 
ments, 4. 



Bow-legs in rickets, 227. 

Bradycardia, 590. 

Brain, diseases of, 699 ; abscess of, 725 ; atrophy 
and sclerosis of, 742; atrophy and sclerosis 
of, in acquired cerebral paralysis, 746 ; cysts 
of, in infantile cerebral paralysis, 740; mal- 
formations of, 699 ; tuberculosis of, 103 ; 
tumour of, 728; water on the, 715; weight 
of, 651. 

Bran bath, 55. 

Breast, abscess of, in newly-born, 115. 

Breasts, care of, during lactation, 160 ; secretion 
of, in newly- born, 114. 

Breast-feeding, 160 ; schedule for, 162. 

Breast milk (see Milk, Woman's). 

Breath, fetid, in scurvy, 214; offensive, in 
ulcerative stomatitis, 248. 

Breathing, noisy, with adenoids, 264 ; stridu- 
lus, in diseases of the larynx, 440, 443, 446 ; 
in retro-oesophageal abscess, 277. 

Bright's disease (see Nephritis), 615. 

Bromides, elimination of, in milk, 137. 

Bronchi, catarrhal spasm of, 475; diphtheria 
of, 959 ; foreign bodies in, 458 ; lesions of, in 
acute broncho-pneumonia, 484 ; lymph nodes 
of, in tuberculosis, 1020; tube casts of, 471. 

Bronchial glauds (see also Lymph Nodes, Bron- 
chial), enlarged, cause of asthma, 474 ; in 
acute broncho-pneumonia, 492 ; refiex cough 
from, 473. 

Bronchitis, acute catarrhal, 462 ; etiology, 462 ; 
lesions, 463 ; symptoms in infants, 463 ; 
symptoms in older children, 465; diagnosis 
from broncho-pneumonia, 465 ; treatment, 
466 ; abortive measures, 467 ; attacks of suf- 
focation, 469 ; cardiac stimulants, 468: coun- 
ter-irritation, 467 ; emetics, 468 ; expectorants, 
468; general management, 467; inhalations, 
468; in infants, mild cases, 468; in infants, 
severe cases, 469; in older children, 469; 
local applications, 467 ; opium, 468; prophy- 
laxis, 466; protracted cough in convales- 
cence, 470; respiratory stimulants, MS; re- 
spiratory failure, 469; asthma following, 475; 
capillary (see Bronoho-pnbumonia, A< dte), 
481, 494; attacks of asthma resembling, 

474; chronic, 471 ; etiology, 171 ; Bympl 8, 

471; diagnosis, 472 ; treatment, 472 ; chronio, 
bronchiectasis in, 472; ohronio, in rickets, 
222; diphtheritio, broncho-pneumonia in, 
505; fibrinous, 470; treatment, 171; in per- 
tussis, 911; in typhoid fever, 1018; spas- 
modic (see \-i H m\ I, 475. 

Bronchiectasis in chronic bronohitis, 472 ; in 
broncho-pneumonia, chronio, 

Broncho-pneumonia, acute, 481 ; bacteriology, 
482 ; complications, 505 ; cyanosis in, 494, 



1096 



INDEX. 



496 ; complicating influenza, 1072 ; diph- 
theria, 962 ; measles, 919 ; pertussis, 941 ; 
pseudo-diphtheria, 1005 ; rickets, 222 ; diag- 
nosis 506 ; from congenital atelectasis, 506 ; 
from severe bronchitis, 506 ; from lobar 
pneumonia, 507 ; from malarial fever, 507 ; 
etiology, 481 ; age, 481 : previous condition, 
481 ; previous disease, 481 ; season, 481 ; sex, 
481 ; duration of, 499 ; lesions, 483 ; in acute 
congestive form (acute red pneumonia), 485 ; 
in mottled red and gray pneumonia, 487 ; in 
gray pneumonia (persistent broncho-pneu- 
monia), 489 ; associated in the lung, 492 ; ab- 
scesses of lung, 493 ; bronchial glands, 492 ; 
emphysema, 493 ; gangrene, 493 ; pleurisy, 
492 ; intra-alveolar haemorrhage, 486 ; pul- 
monary collapse, 484 ; seat of the disease, 
485 ; physical signs, chart of, 500 ; without 
consolidation, 499 ; with areas of partial con- 
solidation, 499 ; with areas of consolidation 
more or less complete, 501 ; day of appear- 
ance, 502 ; protracted or persistent form, 502 ; 
secondary pneumonia with measles, 504 ; ileo- 
colitis, 505 ; influenza, 505 ; pertussis, 503 ; 
diphtheria, 504 ; pleurisy in, 487 ; prognosis, 
507 ; mortality tables, 508 ; protracted cases, 
502 ; pathological differentiation from lobar 
form, 477 ; relative frequency of, 479 ; res- 
piration in, 494, 496 ; symptoms, 493 ; acute 
congestive type, 493 ; acute disseminated 
type, 494 ; common type, 495 ; temperature 
charts of, 497 ; temperature in, 493, 494, 495 ; 
terminations, 491 ; treatment, 509 ; by antipy- 
retics, 511 ; cold, 511 : emetics, 510 ; hygiene, 
510 ; inhalations, 512 ; stimulants, 510 ; of at- 
tacks of collapse, 512; of nervous symptoms, 
512 ; of protracted cases, 512 ; prophylaxis, 
509 ; summary of, 513. 

Broncho-pneumonia, chronic, 534 ; etiology, 
534 ; lesions, 535 ; symptoms, 535 ; physical 
signs, 536 ; course, 536 ; prognosis, 536 ; diag- 
nosis, 536 ; from tuberculosis, 536 ; treatment, 
537. 

Broncho-pneumonia, tuberculous, 1023, 1036 ; 
rapid cases, 1037 ; protracted cases, 1038 (see 
also Tuberculosis, Pneumonia). 

Broths, directions for making, 154. 

Bubo, with gonorrheal urethritis, 638 ; vulvo- 
vaginitis, 642. 

Buhl's disease, 91. 

Calamine lotion, 869. 

Calculi, biliary, 414 ; renal, 630 ; pyelitis with, 

629 ; vesical, 650. 
Calomel fumigations, 448 ; apparatus for, 448 ; 

salivation of nurses, 448 ; statistics of, 449. 
Calomel, how best given, 46. 



Cancrum oris (see Stomatitis, gangrenous), 
254. 

Carbohydrates, function of, in diet, 125. 

Carcinoma of brain, 728 ; of kidney, 624. 

Cardiac cough, 473. 

Carnrick's soluble food, 156. 

Casein in the fasces, 283 ; stools in difficult di- 
gestion of, 365. 

Casts in urine of chronic nephritis, 621. 

Catarrh, Eustachian, in hypertrophy of tonsils, 
273; foetid (see Rhinitis, Atrophic), 435; 
gastric, 298 ; gastro-intestinal, 316 ; nasal 
acute, 428; etiology, 428; symptoms, 429; 
diagnosis, 429 ; treatment, 429 ; prophylaxis, 
430 ; chronic, 431 ; with adenoid growths, 266, 
431 ; foreign bodies in nose, 431 ; nasal polypi, 
432 ; rhinitis, simple chronic, 432 ; hypertro- 
phic, 434 ; atrophic, 435 ; syphilitic, 435 ; 
rhino-pharyngeal, with adenoids, 263. 

Catheters, sizes required for infants, 594. 

Cellulitis of abdominal wall with peritonitis, 
416 ; of neck, in scarlet fever, 900. 

Centrifugal machine, 133, 140. 

Cephalhematoma, external, 95 ; internal, 96 ; 
symptoms, 96 ; diagnosis, 96 ; treatment, 97. 

Cereals, 154 ; allowed from third to sixth year, 
188. 

Cerebellum, abscess of, 725 ; tumours of, 732. 

Cerebral paralysis, 740 ; from haemorrhage, 105 ; 
etiology, 105 ; lesions, 106 ; symptoms, 107 ; 
prognosis, 108 ; treatment, 108. 

Cerebrum, abscess of, 725 ; tumour, 728. 

Chest, circumference of, 20 ; development of, 
24 ; in rickets, 225 ; lateral depressions of, in 
adenoids, 265 ; lateral furrowing of, in rickets, 
222. 

Cheyne-Stokes respiration in acute meningitis, 
711 ; in tuberculous meningitis, 718. 

Chicken pox (see Varicella), 929. 

Chloral, dosage and administration. 57. 

Chlorosis, 799; etiology, 800; lesions, 800; 
symptoms, 800 ; blood in, 800 ; prognosis, 
801 ; diagnosis, 801 ; treatment, SOS. 

Cholera, bacillus of, in milk, 145. 

Cholera infantum, 316 (see also Gastroen- 
teric Infection, Acute), 332. 

Chorea, 673 ; acute endocarditis in, 576 ; course 
and duration, 677 ; diagnosis, 677 ; endocar- 
ditis in, 677 ; etiology, 673 ; following birth 
paralysis, 745 ; typhoid fever, 1013 ; habit, 
679 ; heart murmurs in, 677 ; prognosis of, 
678 : hysterical, 687 ; in adenoids, 265 ; in 
rheumatism, 1088 ; pathology, 675 : post- 
hemiplegic, 681 ; in cerebral palsy, 748 ; prog- 
nosis, 678 ; relation to rheumatism, 674 ; speech 
in, 677, 692 ; symptoms, 676 ; treatment, 678 ; 
urine in, 677. 



INDEX. 



1097 



Circulation, changes in, at birth, 558 ; fcetal, 
558 ; in early life, 558. 

•Circulatory system, diseases of the, 558. 

Claw-hand, 782. 

Cleft palate, 238. 

Clothing at birth, 2 ; in summer, 3 ; at night, 3 ; 
in summer diarrhoea, 326. 

Club-foot with spina bifida, 761. 

Codeine, doses of, 51. 

Cod-liver oil as tonic, 50. 

Cold, as an antipyretic, 47 ; ice cap, 47 ; spong- 
ing, 47 ; pack, 47 ; bath, 48 ; irrigation of the 
colon, 48 ; in the head, with adenoids, 264 ; 
therapeutics of, 53. 

Cold sores, 239. 

Colic, habitual, from excessive proteids, 179 ; 
intestinal, 370 ; renal, 630. 

Colitis, acute (see Ileo-colitis, Acute), 337 ; 
membranous, 349 ; membranous gastritis 
with, 294. 

Collapse, in acute broncho-pneumonia, treat- 
ment of, 512;' in acute peritonitis, 418 ; in ap- 
pendicitis, 392 ; in corrosive gastritis, 296 ; in 
ulcer of stomach, 305. 

Collapse, pulmonary (see Atelectasis, Ac- 
quired), 539. 

Colles's law, 1054. 

Colon, abnormal position of, 308 ; congenital 
atresia of, 115 ; cysts of mucosa, 355 ; dilata- 
tion of, 378 ; in rickets, 229 ; follicular ulcers 
of, 341 ; hypertrophy of, 378 ; irrigation of, 48, 
63 ; in gastro-enteric infection, 329 ; in intes- 
tinal indigestion, 369; membranous inflam- 
mation of, 345 ; transverse, dilatation of, in 
chronic ileo-colitis, 357. 

Colostrum, 127 ; corpuscles of, 127 ; composi- 
tion of, 128. 

Coma, in tuberculous meningitis, 718 ; in dia- 
betes mellitus, 1092. 

Compression-myelitis (see Myelitis), 768. 

Condensed milk, cause of rickets, 215 ; compo- 
sition of, 149 ; dilution of, for infants, 149 ; 
fresh, 149, 150. 

Congenital, ichthyosis, 859 ; myotonia, 682 ; 
rickets, 232 ; syphilis, 1058 ; tuberculosis, 1018. 

Conjunctiva, catarrhal inflammation in measles, 
915 ; haemorrhage from, in newly-born, 104. 

Constipation, a cause of chlorosis, 800 ; causes 
of, in rickets, 229 ; chronic, 372 ; etiology, 
372 ; symptoms, 373 ; diagnosis, 373 ; treat- 
ment, 374 ; food, 374 ; mechanical, 375 ; sup- 
positories, 376; enemata, 376; medicinal, 
377 ; dilatation of colon in, 378 ; from anal 
fissure, 404 ; early symptom of rickets, 223 ; 
from deficient fat in food, 179 ; in appendi- 
citis, 393 ; in intestinal indigestion, chronic, 
364, 366 ; in intussusception, 384. 

80 



Contractures, hysterical, 687. 

Convulsions, 653; etiology, 653; pathology, 
655 ; symptoms, 655 ; diagnosis, 656 ; in 
acute disease, 657 ; in brain disease, 657 ; in 
epilepsy, 657 ; in gastro-intestinal disease, 
657 ; prognosis, 658 ; treatment, 658 ; at- 
tributed to dentition, 244; causing death 
without other symptoms, 44 ; chloral in, 
659; epileptic, 662; hysterical, 688; in ac- 
quired cerebral paralysis, 747 ; in cerebral 
haemorrhages, 107 ; in congenital atelectasis, 
73 ; in pertussis, 941 ; in rickets, 231 ; mor- 
phine in, 659. 

Cooley creamer, 143. 

Cord, spinal, diseases of, 759 ; malformations of, 
759; position of, at birth, 765; meningitis, 
765 ; myelitis, 766 ; pressure-paralysis of, 
768 ; tumours of, 778 ; weight of, 651. 

Cord, umbilical, care of, 1 ; separation of, 2. 

Cornea, ulcers of, in chronic ileo-colitis, 357. 

Corpuscles of blood, 795. 

Coryza, 428 ; early symptoms of measles, 913 ; 
syphilitic, 435, 1059. 

Cough, hysterical, 687 ; reflex, 472 ; from pha- 
ryngeal irritation, 472 ; from elongated uvula, 
472 ; from pharyngeal mucus, 472 ; from 
aural irritation, 472 ; from gastric irritation, 
472 ; from dental irritation, 473 ; from cardiac 
disease, 473 ; of puberty, 473 ; periodical, at 
night, 473 ; from Pott's disease, 473 ; symp- 
toms, 473 ; diagnosis, 473 ; treatment, 473 ; 
spasmodic, in retro-cesophageal abscess, 277 ; 
in tuberculous bronchial glands, 1047; whoop- 
ing (see Pertussis), 936. 

Counter-irritants, 52. 

Cow's milk (see Milk). 

Cranio-tabes, early symptoms in rickets, 223. 

Cranium, syphilitic nodes on, 856. 

Cream, 141 ; to secure different percentages 
of, 142, 174. 

Cream-gauge, 132, 140. 

Credo's method of preventing ophthalmia ne- 
onatorum, 1 ; treatment of ophthalmia, 86. 

Cretinism, sporadic, 752; etiology, 752 ; symp- 
toms, 752 ; diagnosis, 754 ; prognosis and 
treatment, 754. 

Croup, bronchial, 470; catarrhal, 439; kettle, 
58; membranous, 445 ; membranous, in scar- 
let fever, 899 ; spasmodic, 439 ; true, 445. 

Cry, causes and varieties of, 38 : in diseai 
in colic, 371; in retro-pharyngeal abscess, 
260; from insufficient food, 163. 

Cryptorchidism, 637. 

Cups, dry, indications for, 53 ; wet, condemned, 
54. 

Curds and whey, 152. 

Cyanosis, in acute broncho-pneumonia, 494, 



1098 



INDEX. 



496 ; in acute inanition, 195 ; in chronic 
cardiac disease, 582 ; in congenital atelectasis, 
73 ; in congenital disease of heart, 565 ; in 
diphtheritic paralysis, 791 ; in malaria, 1078, 
1080 ; of face, from pressure at root of lung, 
1048. 

Cyclic vomiting, 287. 

Cyst, of brain, 728; of brain in infantile cere- 
bral paralysis, 740 ; of intestinal mucosa, 
355. 

Cysticercus, 396. 

Dactylitis, scrofulous, 849 ; syphilitic, 857 ; 
tuberculous, 849 ; symptoms, 850 ; diagnosis, 
851 ; treatment, 851. 

Deaf-mutism, 758; stigma of degeneration, 
758. 

Deafness following mumps, 949 ; with adenoids, 
264; with hypertrophy of tonsils, 272; sud- 
den, in late syphilis, 1063. 

Death, most frequent causes of, at different 
ages, 41 ; sudden, causes of, 42. 

Deformities, hysterical, 687 ; in rickets, 223. 

Degeneration, stigmata of, 757. 

Deltoid, paralysis of, at birth, 109. 

Dentition, 27 ; eruption of first teeth, 28 ; erup- 
tion of permanent teeth, 29 ; delayed, 28 ; 
before birth, 28 ; difficult, 243 ; symptoms, 
244 ; treatment, 245 ; in rickets, 230 ; in the 
etiology of diarrhoea, 310 ; often delayed in 
malnutrition, 188. 

Dermatitis, exfoliative, of newly-born, 858 ; 
gangrenous, 872 ; treatment, 873. 

Development, conditions interfering with, 30 ; 
muscular, 25 ; of body, 15. 

Dew's method of inducing artificial respiration, 
70. 

Dextro-cardia, 565. 

Diabetes insipidus, 604 ; symptoms, 605 ; di- 
agnosis, 606 ; treatment, 606. 

Diabetes mellitus, 1091 ; symptoms, 1091 ; prog- 
nosis, 1092 ; treatment, 1092. 

Diacetonuria, 603. 

Diagnosis, general considerations in, 31. 

Diapers, 3. 

Diaphragm, hernia through, 116. 

Diarrhoea, acute, eliminative, 312 ; from drugs, 
311 ; from intestinal indigestion, 312 ; from 
nervous influences, 312 ; mechanical, 311 ; 
varieties of, 311 ; etiological factors in, 308 ; 
inflammatory (see IleO-colitis, Acute), 337 ; 
in chronic intestinal indigestion, 364 ; in in- 
testinal tuberculosis, 362 ; mycotic, 316 ; sum- 
mer, 316. 

Diastatic ferment of pancreas, 281 ; of bile, 
281. 

Diathesis, lymphatic, with adenoids, 263. 



Diet (see also Feeding), as cause of chronic 
constipation, 372; cause of rickets, 215; in 
acute gastro-enteric infection, 326 ; in acute 
gastric indigestion, 292 ; in chronic constipa- 
tion, 374 ; in chronic gastric indigestion, 300 ; 
in cyclic vomiting, 289 ; in eczema, 867 ; in 
intestinal indigestion, 368 ; in malnutrition, 
203 ; in rickets, 234 ; in scurvy, 215 ; of nurse, 
effect on milk, 135, 136. 

Dietary of the infant, 126. 

Digestion, gastric, 279 ; duration of, 280 ; in 
infancy, 278 ; intestinal, 281. 

Digestive system, diseases of the, 238. 

Digitalis, dosage for infant, 635. 

Dilatation of the stomach, 302. 

Diphtheria, 951 ; bacillus (see Bacillus of 
Diphtheria), 504; broncho-pneumonia in, 
962, 970; blood in, 962; cardiac failure in r 
968 ; cardiac thrombi in, 961 ; catarrhal, 956 r 
963 ; cervical lymph nodes in, 960 ; com- 
plications and sequoias, 970; convalescence, 
1001 ; croupous bronchitis in, 470 ; diagno- 
sis, 972 ; bacteriological, 976 ; technique of r 
976 ; reliability of, 977 ; clinical, 972 ; from 
pseudo-diphtheria, 974; disinfection after,. 
985 ; distribution and mode of communica- 
tion, 952 ; embolism in, 971 ; entero-colitis in r 
971 ; etiology, 961 ; haemorrhages, 971 ; incu- 
bation, 955 ; lesions, 955 ; membrane, 956 ; 
membrane, seat and distribution of, 957 ; 
membranous gastritis in, 294; proctitis in r 
405 ; myocarditis in, 588, 969 ; nasal syringing 
in, 987 ; nephritis in, 961, 971 ; of oesophagus, 
275 ; otitis in, 879, 970 ; paralysis after, 962 ; 
paralysis in, 790 ; predisposing causes, 954 ; 
prognosis, 980 ; prophylaxis, 981 ; quarantine, 
982 ; septicaemia in, 969 ; sick-room in, 985 ; 
simulated after tonsillotomy, 274 ; sloughing 
in, 969 ; spleen in, 961 ; symptoms, 963 ; symp- 
toms, without membrane, 963 ; symptoms, 
with limited membrane (tonsillar), 964 ; 
symptoms, severe cases, 965 ; symptoms, 
mixed infection (septic), 969 ; thrombosis in r 
971 ; toxaemia, 968 ; toxines of, 956 ; treatment,. 
986 ; general, 986 ; stimulants, 986 ; local, 987 ; 
serum, 988 ; of children exposed, 983 ; of sus- 
pected cases, 983 ; supplementary to antitox- 
ine, 1000 ; virulent bacilli in healthy throats, 
978 ; visceral lesions, 960 ; false (see Pseudo- 
Diphtheria), 1002 ; laryngeal, 445, 967 ; nasal,. 
467, 964, 966 ; pseudo (see Pseudo-Diph- 
theria), 951, 1002 ; scarlatinal (see Pseudo- 
Diphtheria), 1002; scarlatinal, 899 ; scarla- 
tiniform erythema in, 905 ; streptococcus (see 
Pseudo-Diphtheria), 1002; tonsillar, 964. 
Diphtheria antitoxine, dosage of, 990 ; effect 
on membrane, 992; history of, 988; immu- 



INDEX. 



1099 



nizing dose of, 984, 985 ; influence on mor- 
tality of cities, 995 ; limitations of, 992 ; local 
and general effects of, 991 ; other treatment 
with, 1000; production of, 989; real and 
alleged dangers from, 993 ; results in hospital 
practice, 993 ; results in laryngeal cases, 998 ; 
results in private practice, 994; modified by 
time of injection and age of patient, 997 ; of 
intubation with and without, 999 ; strength 
of, 989 ; syringe for, 990 ; time of adminis- 
tration, 991. 

Diplegia, in birth paralysis, 742 ; in meningeal 
haemorrhage, 107 ; spastic, 740. 

Disease, peculiarities of, in children, 30; eti- 
ology, 30; symptomatology and diagnosis, 
31 ; pathology, 38 ; prognosis, 40 ; prophy- 
laxis, 44 ; therapeutics, 45. 

Diverticulum, Meckel's, 112, 308. 

Dobell's solution, 56. 

Dover's powder, dosage of, 51. 

Dropsy (see also (Edema) ; in acute diffuse ne- 
phritis, 616 ; in chronic cardiac disease, 582 ; 
in chronic nephritis, 621 ; in newly-born, 118 ; 
in tuberculosis, 1041 ; without renal disease, 
634. 

Drugs, administration of, 46 ; elimination of, in 
breast milk, 136; well borne, 52; not well 
borne, 52. 

Duct, omphalo-mesenteric, 112, 116. 

Ductus, arteriosus, closure of, 558 ; in foetal cir- 
culation, 558; patent, 564; venosus, closure 
of, 558 ; in foetal circulation, 558. 

Duodenum, catarrhal inflammation of, 297 ; 
congenital atresia of, 115. 

Dura mater, haematoma of, 703 ; thrombosis of 
the sinuses of, 723. 

Dysentery (see Ileo-colitis, Acute), 337. 

Dysphagia, hysterical, 687 ; in retro-pharyngeal 
abscess, 260. 

Dyspnoea, evidences of, 33; from tuberculous 
bronchial lymph nodes, 1048; in acute ca- 
tarrhal laryngitis, 443 ; in catarrhal spasm of 
larynx, 440 ; in membranous laryngitis, 446 ; 
in chronic cardiac disease, 581 ; in retro- 
pharyngeal abscess, 259 ; inspiratory, in 
retro-oesophageal abscess, 277 ; pressure of 
abscess on pneumogastric, 277 ; spasmodic, in 
asthma, 473. 

Ear, anomalies of, as stigmata of degeneration, 

757; haemorrhage from, in newly-born, 104; 

middle, inflammation of (see Otitis), 879. 
Ears, development of hearing, 26. 
Eberth's bacillus of typhoid fever, 1008. 
Ecchymoses in purpura, 810, 811 ; in scurvy, 

209 ; in leucaemia, 807. 
Echinococcus of liver, 414. 



I Eclampsia (see Convulsions), 653. 
Ecthyma gangrenosa, 872. 
Ectocardia, 565. 

Eczema, 862 ; etiology, 862 ; varieties, 864 ; 
diagnosis, 866; prognosis, 866; treatment, 
867 ; dietetic, 867 ; of kidneys, 868 ; of bowels, 
868 ; general, 868 ; local, 869 ; exacerbations 
during dentition, 244 ; intertrigo, 865 ; pustu- 
lar, of scalp, 865; rubrum, 864; seborrhoeic, 
862, 865 ; simple chronic, 864. 
Emboli, infectious, in malignant endocarditis, 

578. 
Embolism, 592; in diphtheria, 971. 
Emphysema, 541 ; etiology, 541 ; lesions, 542 ; 
in acute vesicular, 542 ; in interstitial, inter- 
lobular, 542; symptoms, 543; acute, in bron- 
chitis of infants, 465 ; in acute broncho-pneu- 
monia, 493 ; in pertussis, 941. 
Empyema, 548; bacteriology, 548; lesions, 
549 ; symptoms, 551 ; diagnosis, 551 ; by 
exploratory puncture, 551 ; from unresolved 
pneumonia, 552 ; from pleuro-pneumonia, 552 ; 
from tuberculosis, 552 ; prognosis, 552 ; acute 
peritonitis complicating, 416 ; following 
pleuro-pneumonia, 532; spontaneous cure, 
553 ; treatment, 553 ; by aspiration, 553 ; punc- 
ture with trocar and canula, 554 ; simple in- 
cision and drainage, 554 ; resection of a rib, 
556 ; methods of expanding lung after, 557 ; 
tuberculous, 1023 ; acute broncho-pneumonia, 
492. 
Encephalocele, 699 ; symptoms, 700 ; treatment, 

701. 
Endarteritis, syphilitic, of brain, 1057 ; tuber- 
culous, 715. 
Endocarditis, acute simple, 574 ; etiology, 574; 
lesions, 575; symptoms, 576 ; diagnosis, 576 ; 
prognosis, 577 ; treatment, 577 ; acute simple, 
in chorea, 576; chronic (see also Hkart, 
Valvular Disease), 579; foetal, 568; in 
chorea, 677; in rheumatism, 1087 : malignant, 
578; etiology, 578; lesions, 578; symptoms, 
578; diagnosis, 579; treatment, 579. 
Bnemata, 65; nutrient, 65; drills by, >'<■>: as- 
tringent, in chronic ileo-colitis, :'.. r >9 ; in 
chronic constipation, 376; in colic, 371 : LCS 
water in cholera infantum, 887 ; injuries to 
rectum from, 404. 
Enteritis follioularis (see [lbo-colitis, A.ootj , 

887. 
Bntero-colitis, in diphtheria, '.'71 (see [leo 

colitis, Acute), 337. 
Enuresis, 844; etiology, 845; symptoms, 646; 
prognosis, 646; treatment, 646; stigma of 
degeneration, 758. 
Bpendymitis, acute, in hydrocephalus, 786 ; fol- 
lowing spina bifida, 764. 



1100 



INDEX. 



Epidemic, hemoglobinuria, 90 ; meningitis (see 
Meningitis, Acute). 

Epidermis, exfoliation of, in congenital ichthy- 
osis, 866 ; exfoliation of, in newly born, 858. 

Epilepsy 660 ; aura in, 662 ; course, 664 ; diag- 
nosis, 665 ; etiology of, 660 ; hysterical, 687 ; 
idiopathic, 660 ; in acquired cerebral paraly- 
sis, 748 ; in birth paralysis, 745 ; insanity fol- 
lowing, 756 ; intestinal putrefaction in, 661 ; 
Jacksonian, in cerebral tumour, 731 ; men- 
tal condition in, 664 ; pathology, 661 ; prog- 
nosis, 665 ; status epilepticus, 665 ; stigma of 
degeneration, 758 ; symptomatic, 664 ; symp- 
toms, 662 ; grand mal, 662 ; petit mal, 663 ; 
treatment, general, 666 ; during an attack, 
668. 

Epiphyseal separation in acute arthritis, 835; 
in scurvy, 212 ; in syphilis, 851. 

Epiphyses, enlargement of, in rickets, 227 ; in 
syphilis, 852, 857. 

Epiphysitis, acute (see Arthritis, Acute), 835 ; 
syphilitic, 851, 1061. 

Epispadias, 636. 

Epistaxis, 437 ; in anaemia, 799 ; in pertussis, 
938 ; in purpura, 813 ; in scurvy, 212. 

Epitrochlear lymph nodes in syphilis, 1063. 

Erb's paralysis, 110. 

Erysipelas in newly-born, 83. 

Erythema, following diphtheria antitoxine, 
992 ; in influenza, 1073 ; intertrigo, 865 ; in 
intestinal indigestion, 367 ; in rheumatism, 
1089 ; of the buttocks in marasmus, 207 ; 
scarlatiniform, causes, 905. 

Erythroblasts, 802. 

Estlander's operation, 557. 

Eustachian tube in acute otitis, 879 ; inflamma- 
tion of, in influenza, 1071 ; obstruction of, in 
hypertrophy of tonsils, 272. 

Exercise, importance of, 7 ; caution regarding, 
in heart disease, 587 ; in anaemia, 806. 

Expectorants in bronchitis, 468. 

Eye, anomalies of, as stigmata of degeneration, 
757 ; keratitis, interstitial, in syphilis, 1063 ; 
care of, at birth, 1, 3 ; diphtheritic paralysis 
of, 790; early use, 25; ectropion of, in con- 
genital ichthyosis, 859 ; inflammation of, in 
newly-born, 85 ; in measles, 921 ; nystagmus, 
681. 

Face, asymmetry of, as stigma of degeneration, 
757 ; expression of, in disease, 33 ; cyanosis 
and oedema of, from pressure at root of lung, 
1048. 

Facial paralysis, at birth, 108 ; acquired, periph- 
eral, 792 ; in otitis, 884. 

Faeces, 283 ; of milk diet, 283 ; of mixed diet, 
284 ; incontinence of, 407. 



Fat, determination of, in milk, 133; in the 
faeces, 284 ; test for, 314 ; lack of, a cause of 
rickets, 215 ; lack of, causing constipation, 
372; in woman's milk, 131; percentages of, 
in modification of cow's milk, 171 ; symptoms 
from deficiency of in food, 179 ; symptoms 
from excess in food, 179 ; function of, in diet, 
124. 

Fatty degeneration of the newly-born, 91. 

Fauces, syphilitic, ulceration of, 1057. 

Feeble-mindedness, 750. 

Feeding, artificial, fundamental principles of, 
169 ; rules for, 178 ; schedule for first year, 
178; number of feedings, twenty- four hours, 
178 ; intervals by day, 178 ; night feedings, 
178; quantity for one feeding, 178; quan- 
tity for twenty-four hours, 178 ; versus wet- 
nursing, 158 ; breast, schedule for, 162 ; other 
than milk, first year, 180 ; difficult cases, first 
year, 180 ; daily dietary at eighteen months, 
186 ; for healthy infants, second year, 185 ; 
difficult cases, second year, 187 ; from third 
to sixth year, 188 ; articles allowed, 188 ; arti- 
cles forbidden, 189; dietary, from third to 
sixth years, 190; during acute illness, 190; 
in infants, 190; older children, 192; during 
very hot days, 324 ; by gavage, in acute ill- 
ness, 191 ; in acute gastro-enteric infection, 
326 ; in acute intestinal indigestion, 315 ; 
methods of, in etiology of diarrhoea, 310 ; 
mixed, indications for, 169 ; simple rules in, 
190. 

Feet, anomalies of, as stigmata of degeneration 
757. 

Feser's lactoscope, 140. 

Fever, from insufficient nourishment, 162 ; in- 
anition, 118 ; toxic, in intestinal indigestion, 
367 (see also Temperature). 

Finger (see Dactylitis). 

Fingers, clubbing of, in chronic cardiac dis- 
ease, 582 ; in congenital heart disease, 566. 

Fissure of the anus, 404. 

Fistula, congenital, of the neck, 274. 

Flatulence, cause of colic, 370; in intestinal in- 
digestion, 366. 

Foetal circulation, 558 ; endocarditis, 562. 

Foetus, evidences of syphilis in, 1058. 

Follicles, solitary (see Lymph Nodules); soli- 
tary, of intestine, often enlarged in marasmus, 
205. 

Follicular ulceration of intestine, 341. 

Fomentations, hot, 53. 

Fontanel, bulging, in acute meningitis, 711 ; 
bulging of, in meningeal haemorrhage, 107 ; 
bulging of, in tuberculous meningitis, 715; 
in hydrocephalus, 737 ; closure of, 22 ; in cre- 
tinism, 754 ; in rickety, 224. 



INDEX. 



1101 



Food, constituents, 123 ; proteids, 123 ; fats, 124; 
carbohydrates, 125 ; mineral salts, 126 ; water, 
126; farinaceous, a cause of eczema, 863 : in 
chronic indigestion, 301 ; second year, 185 ; 
improper, in etiology of diarrhoea, 310 ; re- 
gurgitation of, causes and treatment, 179. 

Food-fistula between oesophagus and larynx, 
276. 

Food-diseases, 209. 

Foods, infant, 155; milk, 156; malted, 156; 
farinaceous, 156 ; predigested, danger of 
long use, 123 ; proprietary, dangers of, 122 ; 
cause of rickets, 215; cause of scurvy, 210: 
faults of, 125. 

Foramen ovale, closure of, 559 ; function of, in 
foetal life, 558 ; patent, 564. 

Fractures, green-stick, in rickets, 219, 227. 

Franco-Swiss food, 156. 

Freeman's pasteurizer, 145. 

Friedlander's bacillus in acute broncho-pneu- 
monia, 482. 

Friedreich's ataxia, 780. 

Fruit, best time for giving, 186 ; during second 
year, 186 ; allowed during third to sixth year, 
189 ; forbidden during third to sixth year, 
189. 

Fumigations of calomel, 448. 

Furunculosis, 871 ; treatment, 871 ; in diabetes 
mellitus, 1092. 

Gangrene, of the face, 254 ; of intestine, in in- 
tussusception, 381 ; of lung in acute broncho- 
pneumonia, 493 ; in lobar pneumonia, 516 ; 
in scarlet fever, 903 ; in measles, 920. 

Gastralgia, 290 ; in malaria, 1079 ; in spinal 
caries, 840. 

Gastritis, acute, 293 ; etiology, 293 ; lesions, 
293; catarrhal, 293; gastro-malacia, 293; 
follicular, 294; membranous 1 294; corrosive, 
295; symptoms, 295; catarrhal, 295; corro- 
sive, 296 ; treatment, 296 ; chronic, 298 ; fol- 
licular ulcers in, 304 ; toxic (see Gastritis, 
Corrosive), 295. 

Gastro-enteric infection, acute, 316; etiology, 
317; lesions, 319; simple form, 320; symp- 
toms, 320; diagnosis, 321; from acute indi- 
gestion, 323 ; from ileo-colitis, 323 ; prognosis, 
323; prophylaxis, 324; treatment, hygienic, 
325; dietetic, 326; medicinal, 327; mechan- 
ical, 327; cholera infantum, .'5:52; symptoms, 
332; diagnosis, 335; prognosis, 335; treat- 
ment, 335. 

Gastro-enteritis, 310; in newly-born, 82. 

Gavage, 62; in acute illness, 191 ; in acute in- 
anition, 196; in chronic indigestion, 301; 
in diphtheria, 986; in marasmus, 207; in 
premature infanta, 14; in thrush, 263. 



Genital irritation, 649. 

Genital organs, diseases of, 635 ; anomalies of, 
as stigmata of degeneration, 757 : care of, in 
newly-born, 4 ; malformations of, 635 ; female, 
gangrene of, 254; female, diseases of, 640; 
haemorrhage from, in newly-born, 104 ; males, 
diseases of, 638. 

Gerber's food, 156. 

Gingivitis, haemorrhagic, in scurvy, 212, 214. 

Glands, bronchial (see Lymph Nodes, Bron- 
chial). 

Glands, lymphatic (see Lymph Nodes), 816. 

Glioma of brain, 728 ; of spinal cord, 778. 

Glio-sarcoma of brain, 728. 

Glossitis, 241. 

Glottis, oedema of the, 455 : spasm of, idiopathic, 
671. 

Glycosuria, 599. 

Gonococcus, differentiation of, 642 ; in gonor- 
rhoeal stomatitis, 253; in specific urethritis, 
638 ; in vulvo-vaginitis, 642. 

Gout, eczema in children, 863 ; uric-acid de- 
posits in urine, 602. 

Granuloma of umbilicus, 111. 

Grippe (see Influenza), 1069. 

Growing pains, rheumatic, 1087. 

Growth, conditions interfering with, 30; of 
body, 15 ; extremities, 21 ; trunk, 21. 

Gumma, syphilitic (see Syphilis Lesions), 
1055; in syphilitic bone disease, 855: of 
brain, 728. 

Gums, abscess of, 243; bleeding in ulcerative 
stomatitis, 249 ; inspection of, 35 ; lancing, 
245; spongy and bleeding, in scurvy, 211, 
214; in ulcerative stomatitis, 249. 

Habit-chorea, 679. 

Habit-spasm, 679. 

Habits, injurious, 695. 

Haematemesis, 305. 

I hematoma of the sterno-mastoid, 94. 

Haematozoon malaria?, 1075. 

Ilaematuria, 598 ; in newly-born, 103 ; in pur- 
pura, 812; in pyelitis, 628; in tumours of 
kidney, 624. 

Bamoglobin, 795. 

Haemoglobinuria, 599; epidemic, 90; paroxye 
mal, 599. 

Haemophilia, 808. 

I hemoptysis in tuberculosis, 1041. 

Haemorrhage, from Btomach, .".»>.">; in homo- 

philia, so;* ; intra-alveolar, in acute broncho 
pneumonia, 487 ; internal, causing sadden 
death, \1 ; intestinal, t'rom tuberouloUB uleer, 

862 ; in typhoid fever, 1012 ; meningeal, caua 
ing birth paralysis, 741 ; in acquired cerebral 

paralysis, 746 : in acute broncho-pneumonia. 



1102 



INDEX. 



505 ; in convulsions, 656 ; meningeal, in per- 
tussis, 940 ; meningeal, in purpura, 811 ; nasal, 
in diphtheria, 971 ; pulmonary, in cardiac 
cases, 582 ; rectal, from ulcer, 406 ; in leucaemia, 
807 ; in measles, 921 ; in pertussis, 940 ; in 
pernicious anaemia, 804 ; in purpura, 811 ; in 
the newly-born, 93 ; haematoma of the sterno- 
mastoid, 94 ; cephalhaematoma, 95 ; visceral, 
97; in scurvy, 212, 214; subperiosteal, in 
scurvy, 212 ; in syphilis, 1061. 

Haemorrhagic disease of the newly-born, 98 ; 
etiology, 99 ; lesions, 101 ; symptoms, 102 ; 
diagnosis, 104; prognosis, 104; treatment, 
104 ; Gaertner's bacillus in, 100. 

Haemorrhoids, 407 ; in chronic constipation, 
373. 

Hair, anomalies, stigmata of degeneration, 757. 

Hand, progressive muscular atrophy of, 782. 

Hands, anomalies, stigmata of degeneration, 
757. 

Hare-lip, 238. 

Hawley's food, 156. 

Hay fever, 475. 

Head, circumference of, 20 ; closure of sutures, 
22 ; closure of fontanels, 22 ; shape of, 23 ; 
in rickets, 223 ; examination of, 37 ; hydro- 
cephalic, characteristics of, 737 ; rotary and 
nodding spasm of, 681 ; sweating of, in rick- 
ets, 223. 

Headache, frequent in adenoids, 264 ; varieties, 
689 ; diagnosis, 690 ; treatment, 690. 

Hearing, when developed, 26. 

Heart, diseases of, 558 ; aneurism of, 589 ; aortic 
disease, congenital, 564; area of absolute 
cardiac dulness, 561 ; of relative dulness, 
560 ; auscultation of, 37 ; dilatation of, in 
valvular disease, 580; diphtheritic paraly- 
sis of, 790, 791 ; examination of, 560 ; hy- 
pertrophy of, in congenital disease, 567 ; hy- 
pertrophy of, in valvular disease, 580; in 
measles, 921 ; in scarlet fever, 903 ; malfor- 
mations of, 562 ; peculiarities of, in early 
life, 558 ; persistent foetal conditions, 562 ; 
position of apex beat, 560 ; in infancy. 461 ; 
size and growth of, 559 ; sounds of, redupli- 
cation, 562 ; relative intensity, 561 ; sudden 
failure of, in diphtheria, 968; thrombus of, 
ante-mortem, 592; transposition of, 565 ; con- 
genital anomalies of, etiology, 562 ; diagno- 
sis, 566 ; from acquired disease, 568 ; from 
anaemic murmurs, 568 ; lesions, 562 ; fre- 
quency of, 562 ; secondary, 565 ; prognosis, 
568; symptoms, 565; treatment, 569 ; func- 
tional disorders of, 590 ; symptoms, 590 ; di- 
agnosis, 591 ; prognosis, 591 ; treatment, 591 ; 
murmurs of, 583 ; anaemic, 589 ; in congenital 
disease, 566 ; in chorea, 677 ; in marasmus, 



207 ; prognosis of, 586 ; valves, aortic insuf- 
ficiency, 585 ; murmur of, 585 ; aortic stenosis, 
584 ; murmur of, 584 ; mitral insufficiency, 
583 ; murmur of, 583 ; mitral stenosis, 584 ; 
murmur of, 584 ; congenital absence of, 
valves, 565 ; tricuspid, insufficiency, 585 ; 
murmur of, 585; valvular disease of (see 
also Endocarditis), 574 ; chronic valvular 
disease of, 579 ; lesions, 579 ; etiology, 580 ; 
symptoms, 581 ; clinical varieties, 583 ; prog- 
nosis, 586 ; diagnosis, 587 ; treatment, 587 ; 
ventricle, left, signs of dilatation, 584 ; signs 
of hypertrophy, 583 ; right, signs of hyper- 
trophy, 567. 

Hectic fever in tuberculosis, 1040. 

Height, 21 ; from birth to sixteenth year, 20. 

Hemianopsia in cerebral tumour, 731. 

Hemi chorea, 676. 

Hemiplegia in acquired cerebral paralysis, 747 ; 
in birth paralysis, 742 ; in meningeal haemor- 
rhage, 107 ; in cerebral tumour, 731 ; spastic, 
740. 

Hermaphroditism, false, 636. 

Hernia, cerebri, 700 ; diaphragmatic, 116 ; um- 
bilical, 113. 

Herpes, labialis, 239 ; of the vulva, 643. 

Herpetic stomatitis, 246. 

Hiccough, 682 ; in acute peritonitis, 418 ; in ap- 
pendicitis, 392. 

Hip, articular ostitis of, 843; symptoms and 
stages, 844 ; physical examination, 844 ; diag- 
nosis, 846 ; prognosis, 847 ; treatment, 847. 

Hip-joint disease (see Hip, Articular Ostitis 
of), 843. 

History-taking, 32. 

Hives (see Urticaria), 874. 

Hoarseness with adenoids, 264; in catarrhal 
spasm of larynx, 440; in syphilis, 1060. 

Hodgkin's disease, 831. 

Horlick's food, 156. 

Hubbell's prepared wheat, 156. 

Hutchinson's teeth in late hereditary syphilis, 
1062. 

Hydatids of liver, 414. 

Hydrencephalocele, 699 ; symptoms, 700 ; treat- 
ment, 701. 

Hydrencephaloid, 334; treatment, 337. 

Hydrocele, 639 ; treatment of, 640. 

Hydrocephalus, 734; in chronic basilar menin- 
gitis, 722 ; with spina bifida, 736, 761 ; acute, 
734 (see Meningitis, Tuberculous), 715; 
chronic, external, 734; internal, 734; eti- 
ology, 734 ; lesions, 735 ; symptoms, 736 ; 
prognosis, 739 ; diagnosis, 739 ; treatment, 
740; shape of head, 737; congenital, 702; 
intra uterine, 700 ; spurious, 334 ; treatment, 
337 ; syphilitic, 1057. 



INDEX. 



1103 



Hydronephrosis, 607 ; traumatic, 631 ; with 
malformations of kidney, 609; with renal 
calculi, 630. 

Hydromyelus, 779. 

Hygiene of infancy, 1. 

Hyperaesthesia, general, in acute meningitis, 
710; in infantile spinal paralysis, 773; hys- 
terical, 686; in multiple neuritis, 788; in 
scurvy, 209, 214 ; in spinal meningitis, 766. 

Hypermetropia, stigma of degeneration, 758. 

Hypertrophy of the tonsils, 272 ; pseudo-mus- 
cular, 783. 

Hypodermic medication, 66. 

Hypospadias, 636. 

Hysteria, 685; etiology, 685; symptoms, 686 
psychical, 686 ; sensory, 686 ; joint, 686 
motor and convulsive, 687; diagnosis, 688 
prognosis, 688 ; treatment, 688. 

Hystero-epilepsy, 687 ; treatment of attack, 689. 

Ice, bag, 54 ; cap, 47, 54 ; coil, 54. 

Ichthyosis, congenital, 859; symptoms, 859; 
treatment, 860. 

Icterus, 409 ; in epidemic hemoglobinuria, 96 ; 
in gastro-duodenitis, 297 ; varieties in newly- 
born, 75 ; in malformation of the bile ducts, 
75; physiological or idiopathic, 76. 

Idiocy, 750 ; cretinoid, 752. 

Ileo-colitis, acute, 337 ; etiology, 338 ; lesions, 
338 ; in catarrhal, 339 ; in ulcerative, 341 ; in 
follicular ulceration, 341 ; in membranous, 
343 ; symptoms, catarrhal form, mild, 346 ; 
severe, 347 ; follicular ulceration, 347 ; mem- 
branous form, 349 ; diagnosis, 350 ; from ty- 
phoid fever, 350 ; from intussusception, 350 ; 
prognosis, 351 ; treatment, 351 ; hygienic, 351 ; 
medicinal, 852; mechanical, 352; broncho- 
pneumonia complicating, 505 ; following per- 
tussis, 1*41 ; in influenza, 1072 ; in measles, 
920; chronic, 354; lesions, 354; catarrhal 
form, 354 ; ulcerative form, 355 ; symptoms, 
356 ; diagnosis, 358 ; from general tubercu- 
losis, 358 ; prognosis, 858; treatment, 359. 

Ileum, congenital atresia of. 115. 

Imbecility, 5T50. 

Imperial granum, 156. 

Impetigo, contagiosa, s73 ; simple, 865. 

Inanition, acute, 198; etiology, 194; symptoms, 
194; prognosis, 196; diagnosis, 195; treat- 
ment. 196. 

Inanition fever, 118. 

incubator, 12; in marasmus, 209. 

Indican, in urine of chronic constipation, 878 ; 
of intestinal indigestion, 869 : test for, in 
urine, 602. 

Indicanuria, 602. 

Indigestion, acute gastric, 290: etiology, 2'.»1 ; 



symptoms, 291 ; diagnosis from gastritis, 292 ; 
treatment, 292 ; vomiting in, 285 ; chronic gas- 
tric, 298; etiology, 298; lesions, 298; symp- 
toms, in infants, 298 ; in older children, 300 ; 
treatment in infants, 300 ; in older children, 
302 ; with dilatation, 303 ; acute intestinal, 
313; etiology, 313; symptoms, 313 ; diagnosis, 
314 ; prognosis, 315 ; treatment, 315 ; chronic 
intestinal, 363 ; in young infants, 363 ; lesions, 
364; symptoms, 364 ; treatment, 366; in older 
children, 366 ; symptoms, 366 ; prognosis, 368 ; 
treatment, 368. 

Infant, alimentation of, when premature, 14; 
care of newly- born, 1 ; when premature or 
delicate, 10. 

Infant feeding, 157. 

Infant foods, 155. 

Infarctions, uric acid in kidney, 610. 

Infectious diseases, the specific, 887. 

Influenza, 1069; etiology, 1069; lesions, 1070; 
symptoms, 1070 ; simple uncomplicated type, 
1070; severe uncomplicated type, 1070 ; with 
catarrhal complications, 1071 ; with broncho- 
pulmonary complications, 1071 ; with gastro- 
enteric complications, 1072 ; in very young 
infants, 1072; complications and sequelae, 
1073 ; diagnosis, 1073 ; prognosis, 1074 ; treat- 
ment, 1074; broncho-pneumonia, 505, 1072; 
epidemic, acute otitis in, 879 ; scarlatiniform 
erythema in, 905. 

Inhalations, 58 ; in bronchitis, 468. 

Inheritance a factor in disease, 30. 

Injections, rectal, in ileo-colitis, 353 ; in intus- 
susception, 387 ; subcutaneous, of saline solu- 
tion in cholera infantum, 336. 

Insanity, 755; etiology, 756; symptoms, 756; 
prognosis, 757 ; following typhoid fever, 1013. 

Inspection of sick child, 33. 

Intermittent fever, malarial, 1078. 

Intertrigo, 865; treatment, B70. 

Intestinal obstruction in newly-born, 115; acute, 
from intussusception, 378. 

Intestines, diseases of, 306; amyloid degenera- 
tion of, 360; bacteria of, 282; digestion in, 
281 : haemorrhage from, in newly-born, 103; 
in typhoid, 1012; in tuberculosis, 862; length, 
281; malformations of, 808 ; obstruction, con- 
genital, of, 115; obstruction i>y omphalo-mes- 
enterio duct, 116; perforation of, in tubercu-, 

LOUS peritonitis, 428; in tuberculous 

".'•.l ; in typhoid \r\rr. loo;.. [018; tuberculo- 
sa ,.f, 860, 1082; etiology, 860; lesions, 861 : 
diagnosis, 862; progi . treatment. 

Intubation, in a.-ute catarrhal laryngitis, 446; 
in >\ philitio laryngitis, 468 : results with and 
without antitoxine, 999 ; statistics of, with 



1104 



INDEX. 



calomel fumigations, 449 ; after-treatment in, 
452; advantages over tracheotomy, 454. 

Intubation set, O'Dwyer's, 451. 

Intussusception, 378 ; varieties of, 378 ; etiolo- 
gy, 379 ; lesions and mechanism, 380 ; symp- 
toms, 381 ; course, duration, termination, 384 ; 
diagnosis, 385 ; prognosis, 385 ; treatment, 
386 ; laparotomy, 388 ; in the dying, 279. 

Invagination of intestine in intussusception, 
381. 

Iodides, elimination of, in milk, 136. 

Iritis, syphilitic, 1057. 

Iron, tonic preparations of, 50. 

Irrigation, intestinal, in chronic indigestion, 
369 ; as antipyretic, 48 ; of the colon, method 
of, 63. 

Ischio-rectal abscess, 407. 

Italians, rickets in, 216. 

Jacket, oil-silk, 59. 

Jaffe's test for indican, 602. 

Jaundice (see also Icterus), 409 ; catarrhal, 297. 

Jaw, necrosis of, from alveolar abscess, 243 ; 
in gangrenous stomatitis, 255 ; in ulcerative 
stomatitis, 248. 

Jejunum, congenital atresia of, 115. 

Joints, diseases of, 835 ^hysterical affections of, 
686 ; in scarlet fever, 902 ; rheumatism of, 
1086 ; suppuration of, in newly-born, 82 ; 
swelling of, in scurvy, 209 ; ecchymoses about, 
in scurvy, 209 ; tuberculous diseases of, 836 ; 
etiology, 837 ; lesions, primary, 837 ; second- 
ary, 838. 

Junket, 152. 

Keratitis, interstitial, in late syphilis, 1057, 1063. 

Keratoma, diffuse, 859. 

Kidney, diseases of, 606 ; acute congestion of, 
611; acute degeneration of, 612; benign tu- 
mours of, 627 ; calculi in, 630 ; chronic con- 
gestion of, 611 ; contracted (see Nephritis, 
Chronic), 620 ; cystic degeneration of, 607 ; 
floating, 610 ; granular (see Nephritis, 
Chronic), 620 ; haemorrhage from, in newly- 
born, 104; in scurvy, 214; horseshoe, 607; 
hydronephrosis, 607 ; traumatic, 631 ; malfor- 
mations and malpositions of, 606 ; malignant 
tumours of, 623 ; etiology, 624 ; symptoms, 

. 624 ; diagnosis, 625 ; treatment, 625 ; nephri- 
tis, acute diffuse, 615 ; acute exudative, 613 : 
chronic, 619; perinephritis, 631; pyelitis, 
627 ; pyelo-nephritis, 608 ; pyonephrosis, 627 ; 
single, 607 ; tuberculosis of, 623, 1032 ; uric- 
acid infarction, 610 ; waxy, 620 ; . in diph- 
theria, 961 ; in scarlet fever, 901. 

Klebs-Loefner bacillus (see Bacillus of Diph- 
theria), 951. 



Knee, articular ostitis of, 847 ; symptoms, 848 ; 
treatment, 849 ; subluxation of, in infantile 
spinal paralysis, 774 ; swelling of, in scurvy, 
211 ; white swelling of (see Knee, Articular 
Ostitis). 

Knee-jerk, in acquired cerebral paralysis, 747 ; 
in birth paralysis, 745 ; lost in diphtheritic 
paralysis, 791 ; in infantile spinal paralysis, 
774 ; in multiple neuritis, 788. 

Knee-joint disease (see Knee, Articular Osti- 
tis). 

Knock-knee in rickets, 227. 

Kurayss, 150. 

Kyphosis in rickets, 225 ; treatment, 235 ; in 
spinal caries, 839, 840. 

Lactated food, 156. 

Lactation, care of breasts during, 160. 

Lactometer, author's, 132. 

Lacto-preparata, 156. 

Lactoscope, Feser's, 140. 

La grippe (see Influenza), 1069. 

Landry's paralysis, 781. 

Laparotomy, in chronic peritonitis, with ascites r 
420 ; in intussusception, 388 ; in tuberculous 
peritonitis, 425. 

Laryngismus stridulus, 671 ; symptoms, 672 ; 
diagnosis, 672 ; treatment, 673 ; in rickets,. 
231 ; with tetany, 668. 

Laryngitis, acute catarrhal, 442 ; lesions, 442 ; 
symptoms, 442 ; diagnosis from membranous 
laryngitis, 443 ; prognosis, 444 ; treatment 
444; catarrhal, in measles, 919; chronic, 456; 
with adenoid vegetations of pharynx, 456 ;. 
tuberculous, 456 ; syphilitic, 457 ; with new 
growths of larynx, 458 ; membranous, 445 r 
919; symptoms, 446 ; course, 446; prognosis,. 
447 ; diagnosis, 447 ; treatment, 447 ; by calo- 
mel fumigations, 448 ; operative measures, 
449; antitoxine, 449, 990, 998; intubation, 
450 ; tracheotomy, 449 ; spasmodic, 439 ; sub- 
mucous (oedema of glottis), 455. 

Laryngotomy for foreign body in larynx, 459. 

Larynx, diseases of, 439; catarrhal spasm of, 
439; etiology, 439; lesions, 439; symptoms, 
440 ; diagnosis, 440 ; from laryngismus stridu- 
lus, 440 ; from membranous laryngitis, 441 ; 
treatment, 441 ; from long uvula, 258 ; with 
adenoids, 265 ; diphtheria of, 445, 967 ; re- 
sults of antitoxine in, 998 ; foreign bodies in, 
458 ; intubation of, 450 ; results with and with- 
out antitoxin, 999 ; in measles, 919 ; in pseudo- 
diphtheria, 1003, 1005 ; new growths of, 458 ; 
stenosis of, simulated by tuberculous glands, 
1049 ; syphilis of, 457, 458, 1056 ; tuberculosis, 
of, 456. 

Lassar's paste, 869. 



INDEX. 



1105 



Leptomeningitis, acute (see Meningitis), 706. 

Leucaemia, 806 ; etiology, 806 ; lesions, 806 ; 
symptoms, 807 ; blood, 807 ; course and prog- 
nosis, 808 ; diagnosis, 808 ; treatment, 808. 

Leucocytosis, definition, 797; in diphtheria, 
962 ; in acute meningitis, 711. 

Lichen urticatus (see Urticaria), 874; tropi- 
cus, 861. 

Liebig's food, 156. 

Limewater, in modification of cow's milk, 172. 

Lip, eczema of, 240 ; perleche, 240 ; diseases of, 
239 ; herpes of, 239 ; malformations of, 238. 

Lisping, 691. 

Lithuria, 601. 

Liver, diseases of, 408 ; abscess of, 410 ; acute 
yellow atrophy of, 410 ; amyloid degeneration 
of, 412 ; biliary calculi, 414 ; cirrhosis of, 411 ; 
congestion of, 410 ; displacement of, 37 ; en- 
larged, in congestion, 410; in abscess, 410; 
in cirrhosis (early), 412; in chronic cardiac 
disease, 582 ; fatty, 413 ; fatty, in eczematous 
children, 863 ; in marasmus, 205 ; functional 
disorders of, 409 ; hydatids of, 414 ; in rick- 
ets, 231 ; in syphilis, 1055, 1065 ; in tubercu- 
losis, 1041; lardaceous, 412; malformations 
and malpositions of, 409 ; size and position 
of, 37, 408; tuberculosis of, 1031 ; waxy, 412; 
weight of, in infancy, 408. 

Loeffler's bacillus (see Bacillus of Diph- 
theria), 951 ; blood-serum, 952 ; stain, 952. 

Lumbar puncture, 713 ; tubercle bacilli in fluid, 
720. 

Lung, diseases of, 459 ; abscesses of, in acute 
broncho-pneumonia, 493 ; acute congestion 
of, in malaria, 1080 ; calcareous nodules in, 
1027; caseous degeneration of, 1024; collapse 
of, from compression, 539 ; from obstruction, 
540; in acute broncho-pneumonia, 484; con- 
genital atelectasis of, 72 ; emphysema of, 541 ; 
acute, in bronchitis of infants, 465 ; gangrene 
of, 537 ; etiology, 537 ; lesions, 538 ; symp- 
toms, 538 ; treatment, 539 ; gangrene of, in 
lobar pneumonia, 516 ; haemorrhages into, in 
newly-born, 97 ; inflation of, 71 ; miliary tu- 
berculosis of, 1023; peculiarities in disease, 
462; in infancy and early childhood, 459; 
physical examination of, 460 ; inspection, 
460 ; palpation, 460 ; percussion, 461 ; auscul- 
tation, 461 ; structure of, 460. 

Lymph nodes, diseases of, 816; calcareous cer- 
vical, 826; bronchial, 1030 ; early infection in 
tuberculosis, 1020 ; enlarged, in eczema, 804 ; 
in Hodgkin's disease, 881; in malnutrition, 
198; frequency of disease of, 39; inflamma 
tionof (see Adenitis), 819; in late hereditary 
syphilis, 1063; in measles, 921; in pseudo 
diphtheria, 1004; in scarlet fever, ( J00 ; sim- 



ple hyperplasia of, 822 ; situation and drain- 
age areas of the groups of head and neck, 
819 ; syphilitic disease of, 823 ; tuberculous, 
bronchial, 1047; lesions, 1020, 1028; symp- 
toms, 1047 ; physical signs, 1049 ; diagnosis, 
1049 ; cervical, tuberculosis of, 824 ; mesen- 
teric, 360, 1021 ; etiology, 360 ; lesions, 362 ; 
symptoms, 362 ; diagnosis, 362 ; treatment, 
363 ; in diphtheria, 960 ; in rickets, 230 ; in 
tonsillitis, 270 ; epitrochlear, in syphilis, 1063 ; 
mesenteric, often enlarged, in marasmus, 
205 ; in typhoid fever, 1009 ; tuberculosis of, 
retro-pharyngeal, abscess of, 258. 

Lymph nodules of intestines, ulceration of, 
341. 

Lymphangioma of tongue, 239. 

Lymphatism, 816 ; with adenoids, 263. 

Lymphocytes, 796. 

Magendie, foramen of, in hydrocephalus, 734. 

Malaria, 1075 ; etiology, 1075 ; lesions, 1077 ; 
symptoms, 1077 ; masked and irregular 
forms, 1079 ; subacute or chronic forms, 
1081 ; diagnosis, 1081 ; prognosis, 1082; treat- 
ment, 1082 ; quinine, methods of adminis- 
tration, 1082 ; dosage, 1083 ; acute pulmo- 
nary congestion in, 1080 ; contracted in 
utero, 1076 ; spleen in, 834. 

Malformations as cause of sudden death, 42. 

Malnutrition, 197 ; etiology, 197 ; symptoms in 
infants, 198 ; symptoms in older children, 
198 ; diagnosis, 200 ; prognosis, 201 ; treat- 
ment in infancy, 201 ; treatment in older 
children, 203. 

Malnutrition, marasmus, 204. 

Malted milk, 156. 

Malt extracts, use of, in diet of nurse, 135. 

Maltose, substitute for milk sugar, 125, 183. 

Mania, 756 ; acute, following typhoid fever, 
1013. 

Marasmus, 204 ; etiology, 204 ; lesions, 205 ; 
symptoms, 206; complications, 207; diagno- 
sis, 208 ; from tuberculosis, 208, 1034 ; prog- 
nosis, 208 ; treatment, 208 ; fatty liver in, 
413; general oedema in, 634; modification of 
milk in, 182; sudden death in, 4.!; tubercu- 
losis resembling, 1033. 

Marchand's test for fat in milk, 1"..;. 

Massage, 66; in chronic constipation, 875; in 
malnutrition, 202 ; of breasts to increase milk, 
165. 

Mastitis in the newly-born, 114. 

Mastoid diseases, cerebral abscess following, 
725 ; in acute otitis, 883. 

Masturbation, 696; treatment of, 697; b cause 
of epilepsy, 661 ; of insanity, 756; of func- 
tional disorder of heart, 590. 



1106 



INDEX. 



Matzoon, 151. 

Measles, 910; broncho - pneumonia complica- 
ting, 504 ; complications and sequela?, 918 ; 
desquamation, 915 ; diagnosis, 922 ; digestive 
system, 920 ; duration of infective period, 
912: ears, 879, 921; eruption, 914; etiology, 
910 ; eyes, 921 ; gangrenous dermatitis in, 872 ; 
German (see Rubella), 926 ; haemorrhages 
in, 921 ; hemorrhagic, 915 ; heart in, 921 ; 
ileo-colitis, 920 ; incubation, 911 ; invasion, 
913 ; larynx in, 919 ; lesions, 913 ; lungs, 919 ; 
lymph nodes, 921 ; mode of infection, 912 ; 
mortality, 923 ; otitis, 921 ; predisposition, 
911 ; prognosis, 922 ; prophylaxis, 924 ; pseudo- 
diphtheria in, 1004 ; quarantine in, 924 ; 
symptoms, 913 ; symptoms, mild cases, 916 ; 
symptoms, moderate cases, 916 ; symptoms, 
severe cases, 917 ; throat, 920 ; treatment, 924 ; 
tuberculosis following, 922 ; with other in- 
fectious diseaess 922. 

Meats, allowed from third to sixth years, 188 ; 
forbidden from third to sixth years, 189. 

Meckel's diverticulum, 112, 308. 

Meconium, composition of, 283. 

Mediastinum, anterior, abscess of, 1049 ; tumour 
of, due to tuberculous lymph nodes, 1049. 

Mediastinitis, 570. 

Melancholia, 756. 

Melsena, 103. 

Mellin's food, 156. 

Membrane, in diphtheria, 956 ; in pseudo-diph- 
theria, 1003. 

Meningeal haemorrhage, 105. 703, 746. 

Meninges, diseases of, 699. 

Meningitis, acute, 706 ; abortive cases, 709 ; com- 
mon form, 708 ; course, termination, progno- 
sis, 712 ; diagnosis, 712 ; diagnosis from tuber- 
culous, 713 ; eruptions in, 711 ; etiology, 706 ; 
from acute otitis, 883 ; in newly-born, 82 ; 
in typhoid fever, 1012, 1013 ; purulent, in 
acute broncho-pneumonia, 505 ; fulminating 
cases, 709 ; lesions, 707 ; leucocytosis in, 711 
lumbar puncture in, 713 ; malignant cases 
709 ; nervous system in, 710 ; pulse, 711 
respiration, 711 ; secondary cases, 710 ; speech 
711 ; special senses, 710 ; sporadic cases, 710 
symptoms, 708 ; temperature, 711 ; treatment, 
714 ; with lobar pneumonia, 517 ; with pleuro- 
pneumonia, 532. 

Meningitis, basilar, 715 ; chronic, in infants, 
721 ; lesions, 721 ; symptoms, 721 ; diagnosis, 
722 ; treatment, 723 ; cerebro-spinal (see Men- 
ingitis, Acute), 706 ; epidemic, 706 ; syphi- 
litic, 1057 ; spinal, acute and chronic, 765 ; 
symptoms, 766 ; treatment, 766 ; sporadic, 
706 ; syphilitic, 1057. 

Meningitis, tuberculous, 715, 1031 ; lesions, 715 ; 



etiology, 716 ; symptoms, 717 ; duration, 719 ; 
course, variations of, 719 ; diagnosis, 720 ; 
prognosis, 720: treatment, 721 ; lumbar punc- 
ture in, 720 ; respiratory curve in, 718 ; tem- 
perature curve in, 719. 

Meningocele of brain, 699 ; symptoms, 700 ; 
treatment, 701 ; of cord, 760. 

Meningo-encephalitis, 741. 

Meningo-myelocele, 760. 

Menstruation, eflect on nursing, 134. 

Mercury, elimination of, in milk, 137 ; ulcei-- 
ative stomatitis from, 248 ; in syphilis, 1068. 

Microcephalus, 702. 

Micturition, difficult or painful, 649 ; frequency 
of, 595. 

Miliaria, 860 ; papulosa, 861 ; treatment, 861 ; 
rubra, 860. 

Milk, cow's, 137 ; addition of other substances 
to, 183 ; average percentages of, 171 ; best 
from mixed herd, 138 ; sources of contamina- 
tion, 138 ; transportation of, 139 ; composition 
of, 139 ; average percentages in, from differ- 
ent breeds, 139 ; examination of, 140 ; coagu- 
lation of, in stomach, 280 ; cream, 141 ; con- 
taminated, cause of diarrhoea, 310 : differences 
from human milk, 140 ; diphtheria bacilli in, 
954; essentials of, for infant feeding, 138; 
formula? from diluting, 176 ; modification of, 
at home, 174 ; cream, 174 ; sugar solutions, 
175 ; formula? from diluted cream, 175, 176 ; 
instructions for nurse, 176 ; table of ingre- 
dients for preparing, 177 ; bottles and nip- 
ples, 178 ; rules for artificial feeding, 178 ; 
schedule for first year, 178 ; modification for 
healthy infants during first year, 170 ; how to 
prepare, 176 ; formula? for, 177 ; in difficult 
cases, 181 ; in summer diarrhoea, 327 ; modifi- 
cation required by particular symptoms, 179 ; 
in acute indigestion, 315 ; for difficult cases, 
second year, 187 ; formula? for healthy infants, 
second year, 185 ; in chronic constipation, 
375; pasteurization of, 145; proteids of, 124; 
modifications of schedule for feeding, 174: 
sterilization at 167° F., 145; sterilization of, 
at 212° F., 143 ; sterilized, scurvy ascribed 
to, 210; tubercle bacilli in, 1019; typhoid 
contamination of, 1008 ; condensed (see Con- 
densed Milk), 149 ; peptonized, 148 ; pep- 
tonized, use of, 182 ; preparation at each feed- 
ing, 182 ; dangers from long use of, 183. 

Milk-laboratories, 172. 

Milk-sugar, uses of, as food, 125 ; solution, how 
to prepare, 175, 177. 

Milk, woman's, 127 ; physical characters of, 
127 ; colostrum of, 127 ; daily quantity of, 128 ; 
average quantity at one nursing, 130 ; compo- 
sition of, 130 ; proteids, 124, 130, 141 ; fat, 131 ; 



INDEX. 



1107 



sugar, 131 ; salts, 131 ; reaction, 132; specific 
gravity, 132, 134 ; average percentages of, 171 ; 
conditions affecting composition of, 134; 
menstruation, 134 ; diet, 135 ; drugs, 136 ; 
pregnancy, 137 ; nervous impressions, 137 ; 
examination of, 132 ; quantity, 132 ; determi- 
nation of fat, 133 ; sugar, 133 ; proteids, 124, 
133, 141 ; variations in quality, 134 ; apparatus 
for examining, 134; How established, 127; 
how to modify quantity and quality, 164 ; in- 
dications of scanty supply, 163. 

Modiiied-milk from milk laboratory, 172 ; sam- 
ple prescription, 173 ; schedule for feeding 
from birth, 174. 

Monoplegia, in birth paralysis, 742 ; in cerebral 
haemorrhage, 107 ; in cerebral tumour, 731. 

Morbilli (see Measles), 910. 

Morbus coxarius (see Hip, Articular Ostitis 
of), 843. 

Morbus maculosus Werlhofii (see Purpura), 
810. 

Morphine, dosage of, 51, 418 ; dosage in convul- 
sions, 659; hypodermically in cholera infant- 
um, 336 ; in gastro-intestinal infection, 331. 

Mortality at different ages, 41, 42 : chief causes 
of, 41. 

Morton's fluid, 765. 

Mouth, diseases of (see also Stomatitis), 238, 
245 ; applications to, 253 ; care of, at birth, 1, 
3; haemorrhage from, in newly-born, 103; 
haemorrhages from, in scurvy, 214; malfor- 
mations of, 238 ; mucous patches, in syphilis, 
1060 ; syphilis of, 253 ; tapir, 785 ; syringing 
of, 57. 

Mouth-breathing with hypertrophy of tonsils, 
272; adenoids, 264 ; retro-pharyngeal abscess, 
260. 

Mucous membranes, frequency of involvement 
in childhood, 38 ; in rickets, 230. 

Mucous patches, syphilitic, 1060. 

Mumps, 947 ; complications and sequelae, 949 
diagnosis, 950 ; etiology, 947 ; incubation, 948 
pathology and lesions, 947 ; prognosis, 950 
quarantine in, 948 ; symptoms, 948. 

Murmurs, cardiac (sec Beast Mcumurs). 

Muscles, atrophy of, 781; in infantile spinal 
paralysis, 773 ; in multiple neuritis, 788 ; in 
myelitis, 767 ; contractures of, hysterical, 687 ; 
in acquired cerebral paralysis, 747 ; in birth 
paralysis, 744 ; development of, 25; flabbiness 
of, in rickets, 228; rigidity of, in birth pa- 
ralysis, 745 ; spasm of, about rheumatic joint, 
1086. 

Muscular atony, as cause of chronic constipa 
tion, 373. 

Muscular atrophies, different types of, 781. 

Mustard bath, 54 ; paste, 52 ; pack, 52. 



Myelitis, 766 ; symptoms, 767 ; treatment 767 ; 
compression, from Pott's disease, 768 ; lesions, 
768; symptoms, 769; course and prognosis, 
769 ; diagnosis, 770 ; treatment, 770 ; diffuse, 
767 ; transverse, 767. 

Myelocytes in leucaemia, 807. 

Myocarditis, 588 ; lesions, 588 ; symptoms, 589 ; 
diagnosis, 589 ; treatment, 589 ; aneurism in, 
589 ; toxic, in diphtheria, 792, 969 ; in scarlet 
fever, 903. 

Myopia, stigma of degeneration, 758. 

Myotonia, congenital, 682. 

Nail-biting, 698. 

Nails in syphilis, 1061. 

Neck, cellulitis of, in scarlatina, 900 ; congenital 
fistula of, 274 ; wry (see Torticollis). 

Necrosis of bone in syphilis, 852, 854. 

Negroes, rickets in, 216. 

Nematodes (see Worms, Intestinal), 398. 

Nephritis, acute desquamative, 613 ; acute dif- 
fuse, 615; etiology, 615; lesions, 616; symp- 
toms, 616; prognosis, 617; treatment, 618; 
acute exudative, 613 ; etiology, 613 ; lesions, 
613; symptoms, 614; primary cases, 614; 
secondary cases, 615; treatment, 618; in 
broncho-pneumonia, 506 ; acute parenchym- 
atous, 613; acute septic interstitial, 613; 
chronic, 619 ; etiology, 620 ; lesions, 620 ; 
with exudation, 620 ; without exudation, 621 ; 
prognosis, 622 ; diagnosis, 622 ; symptoms, 
620; treatment, 622; chronic diffuse, with 
hydronephrosis, 608 ; chronic interstitial, 
syphilitic, 1057 ; in diphtheria, 971 ; inter- 
stitial (see Nephritis, Chronic), 620; post- 
scarlatinal, 901. 

Nerves, peripheral, diseases of, 785. 

Nervous impressions, effect of, on nursing, 137. 

Nervous system, diseases of, 651 ; diseases of, 
functional, 653; general hygiene of, .". ; pe- 
culiarities of, in childhood, 652. 

Nestles food, 156. 

Neuritis, multiple, 785; etiology, 785; lesions, 
786; symptoms, 787; course and prognosis, 
788; diagnosis, 789; treatment, 789; after 
diphtheria, 790 ; typhoid fever, 1018; in ma 
laria, 1079; optic, in acute meningitis, 710; 

in eerebral tumour, 780; with cerebral ab- 
9, 727. 
Newly born, diseases of, 67; acute infectious 
diseases of, 7^; acute pyogenic diseases of, 
79; blood in, peculiarities of, 797; oare of, 
l ; diseases or accidents at birth, 80; derma- 
titis exfoliativa, 858 ; facial paralysis in, L08; 
fatty degeneration of, 91 ; hemorrhages in, 
93; hemorrhagic disease of, 98; hyperpy- 
rexia in, 119; inanition fever in, 118; icterus 



1108 



INDEX. 



in, 75 ; infection, 31 ; malformations, 30 ; 
mastitis in, 114; ophthalmia of, 85; pemphi- 
gus in, 92 ; peritonitis in, 415 ; sclerema in, 
116 ; skin of, 858 ; ulcer of stomach in, 304. 

Nightmare, 694. 

Night-terrors, 694. 

Nipples, care of, during lactation, 160; fissure 
of, haematemesis from, 306 ; rubber, choice of, 
178 ; care of, 178. 

Nodding spasm of head, 681. 

Nodes, lymph (see Lymph Nodes). 

Nodules, subcutaneous tendinous, in rheuma- 
tism, 1088. 

Noma of vulva, 644 (see Stomatitis, Gangre- 
nous), 254. 

Nose, diseases of, 428 ; deformities of, in heredi- 
tary syphilis, 436 ; difficulty in blowing, with 
adenoids, 264 ; diphtheria of, 958 ; discharge 
from, with adenoids, 264 ; foreign bodies in, 
431 ; haemorrhage from, 437 ; in newly-born 
103 ; in scurvy, 214 ; in hereditary syphilis 
436, 1056; in late syphilis, 1064; polypi in 
432; pseudo-diphtheria of, 1003; sprays for. 
55 ; syringing, 56. 

Nurse, effect of diet on milk of, 135 ; requisite 
qualities in, 10 ; wet (see Wet-Nubse). 

Nursery, temperature, ventilation, 10. 

Nursing, at night, 162 ; when discontinued, 
162 ; during acute illness, 191 ; during first 
days of life, 160 ; hours for, in newly-born, 
161,162; during illness, 168; importance of 
good habits, 161 ; inadequate, symptoms of, 
162; maternal, contra-indications for, 160. 

Nursing-bottles, choice of, 178 : care of, 178. 

Nutrient enemata, 65. 

..Nutrition, derangements of, 192; acute inani- 
tion, 193 ; malnutrition, 197 ; marasmus, 204; 
faulty, diseases due to, 209 ; importance in 
paediatrics, 122. 

Nystagmus, 681 ; in cerebral haemorrhage, 108 ; 
in hydrocephalus, 739 ; in tuberculous menin- 
gitis, 717 ; stigma of degeneration, 758 ; with 
tumour of crura cerebri, 73. 

Oatmeal water, 155. 

O'Dwyer's intubation set, 451. 

(Edema, in acute diffuse nephritis, 616 ; in 
anaemia, 799 ; in chronic nephritis, 621 ; in 
cardiac disease, 582; in delicate infants, 118; 
in leucaemia, 808 ; of face from pressure at 
root of lung, 1048; general, in marasmus, 
207 ; not from renal disease, 634. 

(Edema glottidis, rare in acute catarrhal laryn- 
gitis, 442 ; in corrosive oesophagitis, 275 ; in 
quinsy, 271. 

Oesophagitis, acute, 275 ; catarrhal, 275 ; corro- 
sive, 275. 



(Esophagus, diseases of, 274 ; abscess behind, 
276 ; congenital narrowing of, 275 ; congenital 
obstruction in, 275 ; diphtheria of, 960 ; mal- 
formations of, 274 ; pseudo-diphtheria in, 275 ; 
stricture of, 275 ; thrush in, 275. 

Oil enemata, 65. 

Oiled-silk jacket, 59. 

Omphalitis in newly-born, 80. 

Omphalo-mesenteric duct, 116, 308. 

Onychia, syphilitic, 1061. 

Ophthalmia, gonorrheal, 85 ; in newly-born, 
85 ; treatment, 86. 

Opisthotonus, cervical, 682 ; hysterical, 688 ; in 
acute meningitis, 710 ; in birth paralysis, 744; 
in meningeal haemorrhage, 107, 108 ; in 
chronic basilar meningitis, 722; in maras- 
mus, 207 ; in tuberculous meningitis, 718^ 

Opium, elimination of, in milk, 136 ; in gastro- 
enteric infection, 330 ; in bronchitis, 468 ; 
preparations and dosage, 51. 

Optic nerve, atrophy of, in cerebral tumours, 
730. 

Orange juice in scurvy, 215. 

Orchitis, in mumps, 949 ; in specific urethritis, 
638 ; syphilitic, 1057 ; tuberculous, 1032. 

Orthopnoea, in chronic valvular disease, 581 ; 
in functional disorders of the heart, 590. 

Osteo-myelitis, acute (see Arthritis, Acute), 
835 ; acute, syphilitic, 852 ; in newly-born, 
82 ; tuberculous, 849 ; symptoms, 850 ; diag- 
nosis, 851 ; treatment, 851. 

Osteo-periostitis, chronic, syphilitic, 853. 

Osteotomy in rickets, 237. 

Ostitis, primary, followed by joint disease, 838 ; 
simulated by scurvy, 214. 

Otitis, acute, 879 ; etiology, 879 ; lesions, 879 ; 
catarrhal form, 880 ; phlegmonous form. 880 ; 
symptoms, 880 ; local appearances, 882 ; diag- 
nosis, 882 ; prognosis, 882 ; complications and 
sequelae, 882; treatment, 884; cerebral ab- 
scess in 725, 883 ; thrombosis of lateral sinus 
in, 883 ; facial paralysis in, 884 ; labyrinth in, 
884 : mastoid disease in, 883 ; meningitis in, 
883 ; chronic, in late syphilis, 1064 ; reflex 
cough from, 472 ; frequent attacks of, with 
adenoids, 264; in influenza, 1071; in scarlet 
fever, 900; in syphilis, 1057; in typhoid 
fever, 1013; adenitis complicating, 821. 

Overlying, causing death by asphyxia, 42. 

Oxyuris vermicularis (see Worms, Intestinal), 
400. 

Ozaena in late syphilis, 1064 (see Rhinitis, 
Atrophic), 435 ; syphilitic, 436. 

Pachymeningitis, acute, 703 ; chronic (interna), 
703; symptoms, 704; treatment, 705 ; syphi- 
litic, 1057 ; meningeal haemorrhage from, 746 ; 



INDEX. 



1109 



hemorrhagic, 703 ; pseudo - membranous, 
703. 
Pack, cold, 47 ; hot, 54 ; mustard, 52. 
Palate, cleft, 238 ; deformities of, stigmata of 
degeneration, 757 ; diphtheritic paralysis of, 
790 ; hard, ulceration of, 250 ; in late syphilis, 
1064 ; soft, lesions of, in hereditary syphilis, 
436. 
Pancreas, ferments of, 281 ; syphilis of, 1057 ; 

tuberculosis of, 1032. 
Paralysis, ascending, 781 ; atrophic (see Paral- 
ysis, Infantile, Spinal), 770 ; birth, 105, 
741; atrophy and sclerosis following, 742; 
meningo-encephalitis, 741 ; secondary degen- 
erations following, 742 ; symptoms, 742 ; diph- 
theritic, 790 ; frequency, 790 ; time of occur- 
rence, 790 ; extent and distribution, 790 ; 
symptoms, 790 ; treatment, 792 ; Erb's, 110 ; 
facial, 108, 792 ; etiology, 793 ; prognosis, 793 ; 
diagnosis and treatment, 794 ; in acute otitis, 
884; hysterical, 688; in compression-myeli- 
tis, 769 ; in multiple neuritis, 787 ; in myelitis, 
767 ; Landry's, 781 ; of face in newly-born, 
108 ; of the upper extremity in newly-born, 
109 ; peripheral, 105 (see also Neuritis, Mul- 
tiple), 785; post-diphtheritic, 962; pseudo- 
hypertrophic, 783 ; simulated by scurvy, 214. 

Paralysis, infautile cerebral, 105, 740 ; acute ac- 
quired, 745 ; birth, 741 ; of intra-uterine origin, 
740 ; varieties and symptoms, 740, 742, 747 ; 
prognosis, 748; diagnosis, 749; treatment, 
749. 

Paralysis, infantile spinal, 770 ; etiology, 771 ; 
symptoms, 772 ; course, 773 ; diagnosis, 776 ; 
from transverse myelitis, 776 ; from mul- 
tiple neuritis, 776 ; from cerebral palsy, 776 ; 
distribution of primary paralysis, 773 ; elec- 
trical reactions, 774, 777 ; residual paralysis 
and deformity, 774 ; prognosis, 777 ; treat- 
ment, 777 ; mechanical, 778. 

Paraplegia, Pott's (see Myelitis, Compression), 
768 ; spastic, 740. 

Paregoric, dosage of, 51. 

Parotitis, epidemic (see Mumps), 947. 

Paste, mustard, 52. 

Pasteurized milk, 145. 

Pathology, general considerations of, 38. 

Pavor nocturnus, 694. 

Pcliosis rheumatica, 815. 

Pelvis, deformities of, in rickets, 227. 

Pemphigus, gangrenosa, 872 ; syphilitic, 1058 ; 
in newly-born, 92. 

Pepsin in stomach secretion, 280. 

Peptonized milk, preparation of, 148; partially, 
148 ; completely, 148. 

Pericarditis, 569 ; etiology, 569 ; acute, in bron 
cho-pneumonia, 506 ; chronic, with adhe 



sions, 573; diagnosis, 572 ; dry, 570; external, 
570 ; in newly-born, 82 ; in rheumatism, 1087 ; 
mediastinal, 570; prognosis, 572; purulent, 
570 ; sero-fibrinous, 570 ; symptoms, 571 ; 
treatment, 573; tuberculous, 570; with effu- 
sion, 570 ; with effusion of blood, 570 ; with 
lobar pneumonia, 517 ; with pleuro-pneu- 
monia, 532 ; with transudation of serum, 569. 

Pericardium, congenital absence of, 565 ; tuber- 
culosis of, 1031. 

Perinephritis, 631; etiology, 631; symptoms, 
632 ; diagnosis, 633 ; diagnosis from hip dis- 
ease, 633 ; diagnosis from psoas abscess, 633 ; 
prognosis, 633 ; treatment, 634 ; acute perito- 
nitis complicating, 416. 

Peritonaeum, diseases of, 415 ; haemorrhage into, 
in newly-born, 97 ; in tuberculosis, 1032. 

Peritonitis, acute, 415; etiology, 415; lesions, 
416; fibrinous, 416; serous, 416; purulent, 
417; symptoms, 417; prognosis, 418; treat- 
ment, 418; chronic, non-tuberculous, 419; 
with ascites, 419 ; foetal, cause of malforma- 
tions, 307 ; in intussusception, 385 ; in newly- 
born, 81 ; in perforative appendicitis, 391 ; 
pelvic, from gonorrhoea, 643; tuberculous, 
420 ; miliary, with general tuberculosis, 421 ; 
miliary, with ascites, 421 ; fibrous form, 422 ; 
ulcerative form, 423 ; with tuberculous mesen- 
teric glands, 424; diagnosis, 424; from cir- 
rhosis of liver, 424 ; from chronic peritonitis, 
424; prognosis, 425; treatment, 425; lapa- 
rotomy in, 425 ; with intestinal ulcers, 361 ; 
with lobar pneumonia, 517. 

Perityphlitis (see Appendicitis), 389. 

Perleche, 240. 

Perspiration (see Sweating), 858. 

Pertussis, 936 ; broncho-pneumonia in, 503, 940 ; 
complications, 940 ; convulsions in, 941 ; diag- 
nosis, 942 ; etiology, 936 ; haemorrhages in, 
940 ; incubation, 937 ; infective period, 937 ; 
lesions, 937 ; nervous system in, 941 ; paraly- 
sis in, 940 ; predisposition to, 936 ; prognosis, 
943 ; prophylaxis, 943 ; respiratory system in, 
940; symptoms, 938; catarrhal Btage, 938; 
spasmodic stage, 938; declining stage, 940; 
treatment, 944; general, 944; local, 944; in- 
ternal, 945. 

Peyer's patches, in typhoid fever, 1009; swol- 
len, in acute ileo-colitis, 340; tuberculosis of, 
361 ; ulceration of, in Lleo-oolitis, 342. 

Pharyngitis, acute, 256 : etiology, 256 ; lesions, 
257; diagnosis, 'i:>~ ; treatment, 257 : uvulitis 
in, 258; chronic catarrhal, syphilitic. 1057. 

Pharynx, disca-- of, 256; adenoid vegetations 
of vault, 263, 431 ; with adenitis, 828 ; diph- 
theria of, 958 ; diphtheritic paralysis of, 791 ; 
lesions of, in hereditary syphilis, 436 ; pseu- 



1110 



INDEX. 



do-diphtheria of, 1003 ; reflex cough from, 
472 ; retro- pharyngeal abscess, 260 ; syphi- 
litic ulceration of, 1057 ; syringing of, 57. 

Phimosis, 635 ; reflex phenomena from, 636. 

Phlebitis, of dural sinuses, 724. 

Phosphorus in rickets, 235. 

Photophobia, in influenza, 1070 ; in measles, 
913 ; in tuberculous meningitis, 717. 

Phthisis, chronic, 1027, 1047. 

Physical examination of the child, 35 ; order to 
be adopted in, 38 ; questions to be investi- 



Pia mater, diseases of (see Meningitis), 706. 

Pick's paste, 870. 

Pigeon- breast in adenoids, 265. . 

Pinworms (see Worms, Intestinal), 400 ; proc- 
titis from, 404. 

Pityriasis of tongue, 240. 

Plasmodium malaria?, 1075. 

Pleura, effusion into, in acute nephritis, 616 ; 
tuberculosis of, 1023, 1030. 

Pleurisy, 543 ; dry, 544 ; lesions, 544 ; symp- 
toms, 545 ; treatment, 545 ; in acute broncho- 
pneumonia, 492 ; purulent (see Empyema) 
548 ; tuberculous, dry form, 544 ; with lobar 
pneumonia, 526 ; with serous effusion, 545 ; 
lesions, 545 ; symptoms, 546 ; physical signs, 
546 ; diagnosis, 547 ; prognosis, 547 ; treat- 
ment, 547. 

Pleuro-pneumonia, 531 ; lesions, 532 ; symp- 
toms, 532 ; prognosis, 533 ; diagnosis, 533 ' 
treatment, 533 ; pericarditis in, 569, 571. 

Pneumococcus, in broncho-pneumonia, 482 ; 
lobar pneumonia, 515 ; peritonitis, 416 ; diph- 
theria, 955, 969 ; empyema, 548 ; epidemic 
meningitis, 706 ; malignant endocarditis, 578. 

Pneumonia, 477; anatomical varieties and classi- 
fication of, 477 ; broncho- (see Broncho- 
pneumonia, Acute), 481 ; catarrhal (see 
Broncho-pneumonia, Acute), 481 ; chronic 
interstitial (see Broncho-pneumonia, Chron- 
ic), 534 ; in newly-born, 81 ; in typhoid fever, 
1013 ; mixed forms, frequency of, 478 ; sources 
of infection, 480 ; varieties, classification, 480 ; 
hypostatic, 534; in marasmus, 205; lob- 
ular (see Broncho-pneumonia, Acute), 481 ; 
pleuro- (see Pleuro-pneumonia), 531 ; syphi- 
litic, 1056 ; tuberculous, 1025 (see also Tu- 
berculosis, Pneumonia) ; course, duration, 
termination, 1044 ; diagnosis, 1044 ; physical 
signs, 1043 ; chronic, 1042. 

Pneumonia, lobar, 514 ; etiology, 514 ; age, 
514 ; previous condition, 515 ; previous dis- 
ease, 515; season, 514; sex, 514; crisis, day 
of, 522 ; frequency of, 521 ; complicating in- 
fluenza, 1072 : complications, 526 ; course, 517 ; 
abortive, 518 ; cerebral, 518 ; prolonged, 518 ; 



short, 518 ; typical, 517 ; diagnosis, 527 ; from 
scarlet fever, 528 ; from tonsillitis, 528 ; from 
gastro-enteritis, 528 ; from malaria, 528 ; from 
cerebro-spinal meningitis, 528 ; from menin- 
gitis, 529 ; from empyema, 529 ; from pleu- 
ritic effusion, 529 ; from broncho-pneumonia, 
527 ; lesions, 515 ; seat of, 515 ; stages of, 516 ; 
variations in, 516 ; in other organs, 517 ; lysis, 
frequency of, 521 ; pathological differentia- 
tion from broncho-pneumonia, 478 ; physical 

* signs, 523 ; charts of, 525 ; in exceptional cases, 
524 ; prognosis, 529 ; relative frequency of, 
479 ; symptoms, 517 ; cerebral, 522 ; convul- 
sions, 523 ; cough, 519 ; expectoration, 519 ; 
nervous, 522; onset, 519; pain,519; respiration, 
519; temperature, 520 ; termination, 526 ; treat- 
ment, 530. 

Pneumothorax in pulmonary tuberculosis, 1024. 

Pock, in vaccinia, 933 ; in varicella, 930. 

Poisons, gastritis from, 295, 296. 

Poisoning, stomach-washing in, 62. 

Poliencephalitis, acute, causing cerebral paraly- 
sis, 746. 

Poliomyelitis, acute (see Paralysis, Infantile 
Spinal), 770. 

Polydactyly, stigma of degeneration, 757. 

Polydipsia in diabetes, insipidus, 604 ; mellitus, 
1091. 

Polypi, nasal, 432 ; rectal, 432. 

Polyuria, 604 ; hysterical, 688 ; in diabetes insi- 
pidus, 605 ; mellitus, 1091. 

Porencephalus, 703. 

Pot-belly in rickets, 229. 

Pott's disease (see Spine, Caries of), 838 ; cervi- 
cal, causing torticollis, 684 ; reflex cough in, 
473. 

Poultices, use and preparation of, 53. 

Powders for skin, 4. 

Praecordia, bulging of, 560, 584. 

Pregnancy, effect on woman's milk, 134, 137; 
effect on nursing child, 168. 

Prematurity, cause of marasmus, 204. 

Prepuce, adherent, 635. 

Prickly heat, 861. 

Proctitis, 404 ; etiology, 404 ; varieties, 405 ; ca- 
tarrhal, 405; membranous, 405; ulcerative, 
405 ; symptoms, 406 ; treatment, 406. 

Prognosis, general consideration of, 40. 

Progressive muscular atrophy, hand type, 782 ; 
peroneal type, 783. 

Prolapsus ani (see also Eectum, Prolapse of), 
402 ; from proctitis, 405 ; in ileo-colitis, 346 ; 
in membranous ileo-colitis, 350. 

Prophylaxis, general consideration of, 44. 

Proteids, determination of, in milk, 133 ; func- 
tion in diet, 123 ; in the fasces, 283 ; of woman's 
milk, 130; percentages of, in modification of 



IXDEX. 



1111 



cow's milk, 171, 179 ; in feeding difficult cases, 
181 : vegetable, 124. 

Pseudo-diphtheria, 951, 1002; bacillus, 978; 
broncho-pneumonia in, 1005 ; communica- 
bility, 1003; diagnosis, 1006; from diphthe- 
ria, 974 ; etiology, 1002 ; frequency, 1002 ; in 
measles, 104; in scarlet fever, 1004; lesions, 
1003; membranous gastritis with, 294; mor- 
tality, 1007 ; prognosis, 1006 ; prophylaxis, 
1007; quarantine in, 1007; streptococcus in, 
1002 ; symptoms, 1004 ; primary cases, 1004 ; 
secondary cases, 1004 ; treatment, 1007. 

Pseudo-hypertrophic paralysis, 783. 

Pseudo-muscular hypertrophy, 783. 

Pseudo-paralysis in rickets, 229 ; in scurvy, 
210, 214 ; in syphilis, 853, 1061. 

Psoas abscess in spinal caries, 842. 

Psoriasis of tongue, 240. 

Puberty, delayed, stigma of degeneration, 758 ; 
in cretins, 754 ; in syphilis, 1065 ; effect of, on 
heart in valvular disease, 581, 586; reflex 
cough of, 473. 

Pulse, examination of, 33 ; in early life, 559. 

Purpura, 809; arthritic, 815; blood in, 812; 
fulminans, 814; gangrenous, 815; haematem- 
esis in, 315 ; haemorrhagica, 809, 813 ; He- 
noch's, 814; primary, 811; lesions, 811; pa- 
thology, 812; clinical types, 813; diagnosis, 
815 ; prognosis, 816 ; treatment, 816 ; rheu- 
matica, 815, 1089 ; simplex, 809, 813'; simulat- 
ing scurvy, 214 ; symptomatic, 810 ; cachectic, 
810 ; infectious, 810 ; neurotic, 811 ; mechan- 
ical, 810; toxic, 810. 

Pyaemia, in newly-born, 79 ; of bone (see Ar- 
thritis, Acute), 835. 

Pyelitis, 627 ; etiology, 627 ; lesions, 627 ; symp- 
toms, 628 ; treatment, 629. 

Pyelo-nephritis, 608, 627. 

Pylephlebitis, 410 ; cause of hepatic abscess, 410. 

Pylorus, atresia of, 284 ; stenosis, dilated stom- 
ach in, 303. 

Pyogenic diseases, acute, in newly-born, 79 ; 
clinical varieties, 80 ; distribution of lesions, 
83; general symptoms, 84; prophylaxis, 84; 
prognosis, 85 ; treatment, 85. 

Pyo-nephrosis following pyelitis, 627. 

Pyo-pneurnothorax in pulmonary tuberculosis, 
1024. 

Pyo-salpinx from gonorrhoeal vaginitis, 643. 

Pyuria, 600; in pyelitis, 628. 

Quartan intermittent fever, 1078. 
Quincke's lumbar puncture, 713. 
Quinine, dosage, 1083 ; methods of administra- 
tion, 1082; scarlatiniform rash, 905. 
Quinsy, 270. 
Quotidian intermittent fever, 1078. 



' Pace, influence of, upon rickets, 216. 

Eachitis (see Pickets), 215. 

Reaction of degeneration in Erb's paralysis,. 
Ill ; in facial paralysis, 109, 793 ; in infantile 
spinal paralysis, 774, 777 ; in multiple neu- 
ritis, 789. 

Rectal injections, astringent, 353 ; tannic acid r 
353 ; hamamelis, 353 ; nitrate of silver, 353 ; 
in acute ileo-colitis, 353 ; opium in, 353 ; 
saline, 353. 

Eectum, diseases of, 402; administration of 
drugs by, 65 : atresia of, 307 ; congenital ob- 
struction of, 115 ; enemata, 65 ; feeding by. 65 ; 
haemorrhage from ulcers of, 406 ; inflamma- 
tion of (see Proctitis), 404; malformations 
of, 307; prolapse of, 402; etiology, 402; 
symptoms, 402 ; treatment, 402 ; ulcers of, 
405. 

Red gum (see Miliaria Rubra), 860. 

Regurgitation of food, causes of, in young in- 
fants, 179 ; nasal, in diphtheria, 791, 966, 975. 

Remittent fever, malarial, 1078. 

Renal calculi, 630 ; renal colic, 630. 

Rennet, ferment in digestion, 280. 

Respiration, artificial, methods of, 70 ; Cheyne- 
Stokes, in meningitis, acute, 711 ; in menin- 
gitis, tuberculous, 718; noisy, at night in 
adenoids, 264; paralysis of, in diphtheria, 
791 ; rapidity and characteristics, 460. 

Respiratory system, diseases of, 428. 

Restlessness at night in rickets, 223. 

Rheumatism, 1085; etiology, 1085; symptoms, 
1086 ; general and articular manifestations, 
1086 ; cardiac, 1087 ; diagnosis, 1089 ; progno- 
sis, 1089 ; treatment, 1090 : chorea in, 674, 
1088 ; endocarditis in, 576, 1087 ; erythema, 
1089; purpura, 815, 1089; scarlatinal, 902; 
simulated by scurvy, 214: subcutaneous 
tendinous nodules, 1088; tonsillitis, 269, 
1088 ; torticollis, 684, 1087. 

Rhinitis, chronic, 432 ; simple, 432 ; hypertro- 
phic, 434; atrophic, 435; syphilitic, 435; 
pseudo - membranous, 437; hypertrophic, 
cause of asthma, 474 

Rhino-pharyngitis, acute, 428 ; in influenza, 
1071 ; with adenoids, 263. 

Rhino-pharynx, diphtheria of, 958; reflex 
cough from, 472; simple catarrh of, in acute 
otitis, 880. 

Ribemont's laryngeal tube, 71. 

Ribs, beading of, early in rickets. 

223; resection of, in empyema, I 

Rice water, 155. 

. 215 : etiology, 215 ; diet, 21 5 : hygiene, 
216; race, 216; pathology, 217; lesions. 218; 
microscopical, 222; vi.-ceral, 2'J2 ; symptoms, 
222 ; in early stages, 223 ; course and tormina- 



1112 



INDEX. 



tion, 231 ; acute, 232 ; (see also Scorbutus), 
210 ; congenital, 232 ; constipation in, 373 ; 
convulsions in, 653 ; diagnosis, 232 ; from 
hydrocephalus, 232 ; from true paralysis, 232 ; 
from syphilis, 233 ; from scurvy, 214, 233 ; 
prognosis, 233 ; prophylaxis, 233 ; treatment, 
234; of deformities, 235 ; dilatation of stomach 
in, 303 ; late, 232 ; spleen in, 833. 

Ridge's food, 156. 

Ringworm of scalp, 877. 

Robinson's patent barley, 156. 

Rotary spasm of head, 681. 

Rotheln (see Rubella), 926. 

Round worms (see Worms, Intestinal), 398. 

Rubella, 926 ; complications and sequelae, 928 ; 
desquamation, 928 ; diagnosis, 928 ; eruption, 
927 ; etiology, 927 ; incubation, 927 ; invasion, 
927 ; post-cervical glands, 928 ; prognosis, 
928 ; symptoms, 927 ; treatment, 929. 

Rubeola (see Measles), 910. 

Saccharomyces albicans in thrush, 251. 

Saint Vitus's dance (see Chorea), 673. 

Saline solution, as rectal injection, 353 ; subcu- 
taneous injection of, in cholera infantum, 336 ; 
in acute inanition, 196. 

Saliva, 279. 

Salivation, avoidance of, in calomel fumiga- 
tions, 448 ; in mumps, 948 ; in ulcerative 
stomatitis, 248. 

Salts, inorganic, in modification of cow's milk, 
172; mineral, function of, in diet, 126; of 
cow's milk, 14; of woman's milk, 131. 

Sarcoma, of brain, 728 ; of kidney, 624 ; of spi- 
nal cord, 778. 

Scabies, 875. 

Scalp, pustular eczema of, 865 ; ringworm of, 
877 ; seborrhea of, 862. 

Scapula, angel-wing deformity of, 776. 

Scarlatina (see Scarlet Fever), 888 ; anginosa, 
1004. 

Scarlatiniform erythema, causes of, 905. 

Scarlet fever, 888 ; adenitis following, 820 ; al- 
buminuria in, 901 ; angina in, 899 ; membra- 
nous, 899 ; gangrenous, 900 ; cellulitis of neck 
in, 900 ; complications and sequelae, 899 ; des- 
quamation, 892; diagnosis, 904; diphtheria 
in, 899 ; disinfection after, 906 ; duration of 
infective period, 890 ; eruption, 891 ; etiology, 
888 ; gangrene in, 903 ; heart in, 903 ; incu- 
bation of, 889 ; invasion, 891 ; joints in, 901 
kidneys in, 901 ; lesions, 891 ; lungs in, 902 
lymph nodes in, 900 ; mode of infection, 889 
mortality in, 905 ; myocarditis in, 588 ; other 
infectious diseases with, 903; otitis in 879, 
900; predisposition to, 888; prognosis, 905; 
prophylaxis, 906 ; pseudo-diphtheria in, 899, 



1004 ; quarantine in, 906 ; relapses, recur- 
rences, and second attacks, 898 : symptoms, 
891 ; mild cases, 893 ; moderate cases, 894 ; 
severe cases, 895 ; malignant or cerebral cases, 
897 ; surgical, 897 ; throat in, 899 ; treatment, 
908. 

Schultze's method of inducing artificial respira- 
tion, 70. 

Sclerema, 116 ; in cholera infantum, 335. 

Scorbutus, 209; etiology, 210; symptoms, 211 ; 
lesions, 212; diagnosis, 214; prognosis, 214; 
treatment, dietetic, in, 215 ; ulcerative stoma- 
titis in, 248. 

Scrofula (see Adenitis, Tuberculous), 824; 
(see Tuberculosis). 

Scurvy (see Scorbutus), 209. 

Seborrhcea, 862. 

Seborrhoeic eczema, 865. 

Seller's alkaline solution, 56. 

Senses, special, development of, 25. 

Sepsis in newly-born, 79. 

Septum nasi, ulcer of, with haemorrhage, 439. . 

Serous membranes, frequency of involvement, 
38. 

Serum-therapy of diphtheria, 988. 

Sewer-gas, influence on sore throat, 1003. 

Shock in intussusception, 384. 

Shower bath, 55. 

Sight, when developed, 25. 

Sigmoid flexure, length, 281. 

Singultus, 682. 

Sinuses of dura mater, thrombosis of, 723; lat- 
eral, in otitis, 883. 

Skin, diseases of, 858; anomalies of, as stig- 
mata of degeneration, 757; of newly- born, 
858 ; care of, in newly-born, 4. 

Skull, asymmetry of, in birth paralysis, 745 ; 
sutures, separation of, in hydrocephalus, 737 ; 
syphilitic nodes on, 856. 

Sleep, disorders of, 692 ; disturbed, 7, 692 ; from 
insufficient food, 163 ; in hypertrophy of ton- 
sils, 272 ; in intestinal indigestion, 366 ; in 
rickets, 223 ; with adenoids, 264 ; excessive, 
695; inspection during, 32; proper periods 
of, 6. 

Sleeplessness, 692. 

Smallpox, protection against (see Vaccina- 
tion), 931. 

Smegma, 635, 638. 

Smell, sense of, when developed, 27. 

Snoring, with adenoids, 264 ; hypertrophied 
tonsils, 272. 

Snuffles, syphilitic, 435, 1059. 

Spasm, carpo-pedal (see Tetany), 668; habit, 
679 ; nodding, of the head, 681 ; rotary, of the 
head, 681. 

Speech, disorders of, 690 ; when acquired, 27. 



INDEX. 



1113 



Spina bifida, 759 ; varieties, 760 ; symptoms, 
762; prognosis, 764; diagnosis, 764; treat- 
ment, 764; with congenital hydrocephalus, 
736. 
Spina ventosa (see Osteo-myelitis, Tubercu- 
lous), 849. 
Spinal cord (see Cord, Spinal), 759. 
Spine, angular curvature of, in caries, 841 ; 
caries of, 838 ; symptoms, 839 ; cervical, 839 ; 
dorsal, 840; lumbar, 840; physical examina- 
tion, 841 ; course, 841 ; prognosis, 842 ; diag- 
nosis, 843 ; treatment, 843 ; abscesses in, 842 ; 
causing compression of cord, 769 ; curvature 
of, in hip disease, 846; hysterical affections 
of, 686 ; in rickets, 225 ; lateral deviation of, 
843 ; Pott's disease of (see Spine, Caries of), 
838. 
Spleen, diseases of, 832 ; amyloid degeneration 
of, 834 ; displacement of, 37 , enlargement of, 
837 ; in acute disease, 833 ; in chronic cardiac 
disease, 582 ; in chronic disease, 833 ; in cirrho- 
sis of liver, 412 ; in leucaemia, 806 ; in malaria, 
1079 ; in pseudo-leucsemic anaemia, 801 ; in 
rickets, 222 ; in simple anaemia, 798 ; in ty- 
phoid fever, 1010 ; with amyloid liver, 413 ; 
in diphtheria, 961 ; in hereditary syphilis, 
1056 ; in late syphilis, 1065 ; in tuberculosis, 
1041 ; new growths and tumours of, 834 ; posi- 
tion and methods of examination, 832 ; weight, 
832. 
Sponge bath, cold, 55. 
Sponging, cold, 47. 

Spotted fever (see Meningitis, Acute), 712. 
Spray, nasal, 55; steam, 59. 
Sprue (see Thrush), 250. 
Spurious hydrocephalus, 334. 
Stammering, 691. 

Staphylococcus, in pseudo-diphtheria, 1002 ; in 
furunculosis, 871 ; in acute broncho-pneu- 
monia, 482 ; in diphtheria, 960 ; in empyema, 
549. 
Starch, in the faeces, test for, 284; objections to, 

as food of young infants, 125. 
Stenosis, laryngeal, in acute catarrhal laryn- 
gitis, 442; in membranous laryngitis, 446; in 
syphilitic, 457; of pylorus, dilated stomach 
in, 303. 
Stercoraceous vomiting, in appendicitis, 392; in 

intussusception, 382. 
Sterilization of milk, 143; changes produced 
by, 144; at 212° P., 144; at low temperature, 
145 ; indications for, 147. 
Sterno-mastoid, haematoma of, 94; spasm of 

(see Torticollis). 
Stigmata of degeneration, 757. 
Stimulants, alcoholic, 49 ; indications, 49 ; 
contra-indications, 49 ; administration, 49. 
81 



Stomach, diseases of, 278 ; absorption from, 281 ; 
bacteria of, 281; capacity of, 279; congestion 
of, in acute gastro-enteric infection, 320 ; de- 
velopment of, 279 ; digestion in, 279 ; dura- 
tion of, 280; dilatation of, 302; in chronic 
gastric indigestion, 299 ; in rickets, 229 ; haem- 
orrhage from, 305 ; in newly-born, 103 ; in 
scurvy, 214 ; inflammation of (see Gastritis), 
293; malformations and malpositions of, 284; 
round ulcer of, in chlorosis, 800 ; thrush in, 
252, tuberculosis of, 1032 ; ulcer of, 304 ; in 
newly-born, 304; from follicular gastritis, 
304; tuberculous, 304; round, perforating, 
304; symptoms, 305; treatment, 305. 
Stomach- washing, in acute gastritis, 296; in 
acute indigestion, 292; in chronic indiges- 
tion, 300 ; in gastro-intestinal infection, 328 ; 
method, 60 ; indications for, 61. 
Stomatitis, aphthous (see Herpetic Stomatitis), 
246 ; catarrhal, 245 ; etiology, 245 ; lesions, 245 ; 
symptoms, 245; treatment, 246; in measles, 
920; diphtheritic, 253, 959; follicular (see 
(Herpetic Stomatitis), 246; gangrenous, 254; 
etiology, 254; lesions, 254; symptoms, 254; 
treatment, 256; gonorrhoeal, 253; treatment, 
253 ; herpetic, 246 ; etiology, 246 ; lesions, 
symptoms, 247 ; treatment, 248 ; parasitic (see 
Thrush), 250; syphilitic, 253; ulcerative, 
248 ; etiology, 248 ; lesions, 248 ; symptoms, 
248; treatment, 249; vesicular (see Herpet- 
ic Stomatitis), 246. 
Stone, in the kidney, 630; in the bladder. 650. 
Stools, blood in, from ulcer of stomach, 304; in 
catarrhal ileo-colitls, 346, 347; in membra- 
nous ileo-colitis, 350 ; in intussusception, 882, 
383; in purpura, 813; fat in, test for, 314; 
green, explanation of, 314; in acute intestinal 
indigestion, 314; in cholera infantum, 
in gastro-duodenitis, 297 ; in intestinal indi- 
gestion, chronic, 364, 367 ; in simple gastro- 
enteric infection, 321 ; indication of improper 
feeding, 163; mucus in, in malnutrition, 200; 
undigested casein in. in chronic gastric in<li- 
:_ r ' stion, 299. 
Strabismus, in acute meningitis, 711 ; Btigmaof 
degeneration, 757; with tumour of crura 
cerebri, 781. 
Streptococcus, antitoxins, 1007; pyogenes, in 
acute broncho-pneumonia, 482; in complica- 
tions of scarlet fi in dermatitii 
grenosa, 873; in diphtheria, 169; in 
empyema, 54s ; in peritonitis, acute, 416; in 
pseudo-diphtheria, 1002; in scarlet fever, 888. 
Stridor, in catarrhal spasm of larynx, 440; in 

acute catarrhal laryu 
Strophulus i see Mii.iakiv Bubba.), 860; (see 
Urticaria), 874. 



1114 



INDEX. 



Struma (see Tuberculosis). 

Strychnine in acute broncho-pneumonia, 510. 

Stupe, turpentine, 52. 

Stuttering, 691. 

Subcutaneous tendinous nodules in rheuma- 
tism, 1088. 

Sucking, 278 ; as a bad habit, 695. 

Sudamina, 860. 

Sudden death, chief causes of, 42. 

Sugar, cane, derivatives in digestion, 281 ; sub- 
stitute for milk-sugar, 125, 183; milk, deter- 
mination of, 133 ; in feeding difficult cases, 
181 ; percentage of, in woman's milk, 131 ; 
milk, derivatives in digestion, 281 ; percent- 
ages of in modification of cow's milk, 171 ; 
solutions, rules for making 175; stools in 
difficult digestion of, 365 ; symptoms of de- 
ficiency of, in food, 179 ; symptoms of excess 
of, in food, 179. 

Summer diarrhoea, 316. 

Suppositories, in chronic constipation, 376 ; 
medicated, 376 ; proctitis from long use of, 
404. 

Suprarenal capsules, in syphilis, 1057; tuber- 
culosis, 1032 ; haemorrhage into, 98. 

Sutures, closures of, 22 ; premature ossification, 
23 ; separation of, in hydrocephalus, 737. 

Sweating, in infants, 858 ; of head in rickets, 
223 ; in tuberculosis, 1040. 

Symptomatology, general considerations, 31. 

Syndactyly, stigma of degeneration, 757. 

Synovitis, acute purulent (see Arthritis, 
Acute), 835 ; scarlatinal, 902. 

Syphilis, 1052 ; acute epiphysitis in, 851 ; symp- 
toms, 852 ; diagnosis, 853 ; treatment, 853 ; 
acute osteo-myelitis in, 852 ; bone lesions in, 
851 ; chronic osteo-periostitis in, 853 ; lesions, 
854; symptoms, 856; diagnosis, 856; treat- 
ment, 857 ; dactylitis in, 857 ; of larynx, 457 ; 
pseudo-paralysis in, 853 ; spleen in, 833 ; ac- 
quired, 1052 ; symptoms, 1053. 

Syphilis, hereditary, 1053 ; adenitis in, 823 ; 
bones, 1055 ; Colles's law, 1054 ; coryza, 1059 ; 
diagnosis, 1065; eruption, 1060; etiology, 
1053 ; evidences of, in foetus, 1058 ; fissures 
and mucous patches, 1060; genito-urinary 
organs, 1057 ; haemorrhages, 1061 ; lesions, 
1055 ; liver, 1055 ; nails, 1061 ; nervous sys- 
tem, 1057 ; nose, 1056 ; organs of special sense, 
1057 ; prognosis, 1065 ; prophylaxis, 1066 ; 
pseudo-paralysis, 1061 ; rhinitis of, 435 ; 
spleen, 1056 ; symptoms, 1058 ; at birth, 1058 ; 
date of appearance, 1059 ; constitutional, 
1059; local, 1059; treatment, 1067; local, 
1069; late hereditary, 1062; bones, 1063; 
skin, 1064 ; spleen, 1065 ; teeth, 1062 ; tertiary, 
chronic laryngitis in, 457 ; intubation, 458. 



Syringe, nasal, 56 ; for antitoxine, 990. 
Syringo-myelia, 779. 
Syringo-myelocele, 761. 

Tache cerebrate in tuberculous meningitis, 718. 

Tachycardia, 590. 

Taenia, cucumerina or elliptica, 396 ; flava 
punctata, 397 ; nana, 397 ; saginata or medio- 
canellata, 396 ; solium, 396. 

Tannic acid as rectal injection, 353. 

Tapeworms, 395. 

Tar ointment in eczema, 870. 

Taste, when developed, 27. 

Teeth, 27 ; eruption of first set, 28 ; permanent 
set, 29 ; presence at birth, 28 ; care of, 3 ; de- 
cayed, cause of adenitis, 823; delayed, in 
rickets, 230; grinding of, in intestinal in- 
digestion, 366 ; Hutchinson's, in syphilis, 
1062. 

Teething, reflex symptoms from, 243. 

Temperature, at birth, 35 ; best taken in rec- 
tum, 35; in childhood, 35; subnormal, 36; 
raised by artificial heat, 36 ; variations of, in 
health, 36 ; general consideration of, 46 ; of 
nursery, 9. 

Tenesmus, from proctitis, 405 ; in intussuscep- 
tion, 384 ; in membranous ileo-colitis, 350 ; 
treatment of, 353. 

Tent for inhalation and vapourization, 58. 

Tertian intermittent fever, 1078. 

Testicle, retraction of, with renal calculus, 630 ; 
syphilis of, 1057 ; tuberculosis of, 1032 ; un- 
descended, 637. 

Tetanus, in the newly-born, 87 ; lesions, 88 ; 
symptoms, 88; prognosis, 89; prophylaxis, 
89 ; treatment, 89 ; antitoxine in, 90. 

Tetany, 668; etiology, 668; pathology, 669; 
symptoms, 669 ; duration, 669 ; diagnosis, 
670 ; prognosis, 671 ; treatment, 671 ; in rick- 
ets, 231 ; Trousseau's symptom in, 669. 

Therapeutics, general consideration of, 45. 

Thirst, in diabetes insipidus, 605 ; mellitus r 
1091 ; in hot weather, 324. 

Thomsen's disease, 682. 

Thoracoplasty, 557. 

Thorax, description of, 459 ; measurements of, 
20, 24 ; causes of deformity, 24. 

Threadworms (see Worms, Intestinal), 400. 

Throat, diseases of (see Pharynx and Ton- 
sils) ; importance of inspection of, 37. 

Thrombosis, 593 ; cachectic, of dural sinuses,. 
723 ; in diphtheria, 961, 971 ; in infectious dis- 
eases, 593; inflammatory, of dural sinuses, 
724 ; of internal jugular vein, 593 ; of lateral 
sinus in acute otitis, 883 ; of sinuses of dura 
mater, 723 ; of the aorta, 593 ; of the vena 
cava, 593 ; septic, of dural sinuses, 724. 



INDEX. 



1115 



Thrush, 250 ; etiology, 250 ; lesions, 251 ; symp- 
toms, 252 ; treatment, 252. 

Thymus, abscess of, syphilitic, 1057 ; dulness 
due to, 461 ; enlargement of, causing convul- 
sions, 43 ; tuberculosis of, 1032. 

Thyreoid extract in cretinism, 755. 

Thyroid gland, congenital, absence of, in cre- 
tinism, 752. 

Tibia, deformities of, in rickets, 228 ; enlarged 
epiphysis in rickets, 218; sabre- blade de- 
formity in syphilis, 854. 

Tinea tonsurans, 877 ; treatment, 878. 

Toes, clubbing of, in congenital heart disease, 
566. 

Tongue, diseases of, 240 ; bifid, 239 ; congenital 
hypertrophy of, 239; epithelial desquama- 
tion of, 240 ; geographical, 241 ; inflamma- 
tion of, 241 ; malformations of, 239 ; ulcer of 
frenum, 242. 

Tongue-sucking, 698. 

Tongue-swallowing, 242. 

Tongue-tie, 239. 

Tonics, 50. 

Tonsils, diseases of, 268 ; anatomy of, 268 : 
chronic hypertrophy of, 272; etiology, 272; 
symptoms, 272 ; treatment, 273 ; diphtheria 
of, 958, 964 ; hypertrophy of, cause of asthma, 
474 ; hypertrophy of, in rickets, 230 ; removal 
advised in tuberculous adenitis, 830 ; with 
adenitis. 823 ; pseudo-diphtheria of, 1003 ; 
membrane upon, in scarlet fever, 891. 

Tonsillitis, acute catarrhal, 268 ; croupous (see 
Pseudo-Diphtheria), 1002 ; follicular, 269 ; 
etiology, 269 ; lesions, 269 ; symptoms, 269 ; 
diagnosis, 270 ; treatment, 270 ; in rheuma- 
tism, 1088 ; phlegmonous, 270 ; etiology, 270 ; 
symptoms, 271 ; treatment, 271 ; acute otitis 
in, 879. 

Tonsillotomy, 273. 

Torticollis, 683 ; etiology, 683 ; prognosis, 684 ; 
treatment, 685 ; congenital, 684 ; from cer- 
vical Pott's disease, 684, 840 ; from hema- 
toma of sterno-mastoid, 94 ; hysterical, 687 ; 
in phlegmonous tonsillitis, 271 : in retro 
pharyngeal abscess, 280; malarial, 684, 1079; 
rheumatic, 684, 1087 ; spasmodic, »;-;;. 

Touch, when developed, 26. 

Toxaemia, in intestinal indigestion, chronic, 
365; vomiting in, 286; in acute gastric indi- 
gestion, 291. 

Toxines, of diphtheria, 956. 

Trachea, diphtheria of, 959. 

Tracheotomy, for foreign body in larynx, 459; 
in membranous laryngitis, statistics of, 449, 
999; in retro-oesonha^eal abscess, 278. 

Trismus, in tetanus, 87. 

Trypsin, 281. 



Tubercle bacilli (see Bacillus of Tubercu- 
losis), 1020. 

Tuberculin test in herds, 138. 

Tuberculosis, 1016 ; age, 1017 ; anaemia, 1042 ; 
bacillus of (see Bacillus of Tuberculosis), 
1016; of, in milk, 145; brain, 1031; bron- 
chial lymph nodes in, 1020 ; clinical forms 
of, 1033 ; broncho-pneumonia, 1023, 1036 ; 
chronic phthisis, 1047 ; chronic pulmonary, 
1027 ; congenital, 1018 ; cases resembling 
marasmus, 1033 ; cases resembling a contin- 
ued fever, 1034 ; cough, 1040 ; course, 1044 ; 
chronic, 1027, 1042 ; diagnosis from maras- 
mus, 208, 1034; from typhoid, 1036; from 
broncho-pneumonia, 1044 ; etiology, 1016 : 
expectoration, 1041 ; general, 1033 ; following 
measles, 922 ; following pertussis, 943 ; fre- 
quency, 1016 ; haemoptysis, 1041 ; incipient, 
symptoms in, 1025; intestines, 360, 1032; in- 
tra-uterine infection, 1018 ; kidney, 623, 1032 
lesions, 1022 ; lesions, pulmonary, 1023 
lesions, visceral, frequency of, 1022 ; liver 
1031, 1041 ; lungs, calcareous nodules in 
1027 ; caseous degeneration of, 1024 ; cavitie: 
in, 1024, 1043; lymph nodes, bronchial, 1028 
1047 ; diagnosis, 1049 ; physical signs, 1049 
mesenteric, 360, 1021 ; mode of infection, 1018 
of larynx, 456 ; of lymph nodes, cervical, 824 
of pancreas, 1032 ; paths of infection, 1020 
pericarditis in, 571 ; physical signs, 1043 
pleura in, 544, 1030 ; pleuritic pain, 1041 ; pre- 
disposing causes, 1017 ; prognosis, 1050 ; pro- 
phylaxis, 1050 ; spleen, 834,1031,1041 ; stom- 
ach in, 1032; suprarenal capsules, 1032; 
sweating, 1040; testicle, 1032; thymus gland 
in, 1032 ; treatment, 1051 ; ulcerative ap- 
pendicitis in, 390; uro-genital organs, 1082 ; 
varieties at different ages, 1032 ; wasting, 
1040. 

Tuberculous, adenitis, B24; meningitis. T1-". ; 
nephritis, 628 ; ostitis, 886; pericarditis, 570; 
peritonitis, 120; pleurisy, 544; pneumonia, 
1036. 

Tumour, abdominal, in intussusception, 888 

cerebral, 728; varieties, 728; location, T'-! s 

etiology, 729; symptoms, 7 •-".'; general, 729 
local, 7:'." ; diagnosis, 782 ; from cerebral ah 
Boess, 788; from tuberculous meningitis, 788; 
from chronic basilar meningitis, 788; from 
chronic hydrocephalus, 788; prognosi 
treatment. 788; tuberoulous, L081; fatty, in 
cretinism, 754; of spinal cord, 77^: medi 
astinal, tuberculous lymph nodes, 1049; of 

spleen, 384, 1065. 

Tunica vaginalis, hydrocele of, 689. 

Turpentine Bl Upe, preparation 

Tympanites in acute peritonitis, 417 ; inintes- 



1116 



INDEX. 



tinal indigestion, 366 ; in rickets, 229 ; in ty- 
phoid fever, 1010. 

Typhlitis (see Appendicitis), 389. 

Typhoid fever, 1008 ; age, 1008 ; bacillus of, in 
milk, 145; baths in, 1016; complications and 
sequelae, 1013 ; bowels in, 1010 ; diagnosis, 
1014; duration, 1011; eruption, 1010; etiol- 
ogy, 1008; intestinal haemorrhage in, 1012; 
intestinal perforation in, 1009, 1013 ; lesions, 
1009 ; nervous symptoms, 1012 ; onset, 1009 ; 
prognosis, 1015 ; relapses, 1012 ; scarlatini- 
form erythema in, 905; spleen, enlarged in, 
1010 ; symptoms, 1009 ; temperature, 1011 ; 
treatment, 1015 ; ulcerative appendicitis in, 
390. 

Ulcers, catarrhal, of intestine, 341 ; follicular, 
of intestine, 341 ; following tuberculous ade- 
nitis, 828; of stomach, 304; follicular, 294; 
tuberculous, of skin, 828, 1064; syphilitic, 
1064 ; tuberculous, of intestine, 361, 1032 ; 
typhoid, 1009. 

Umbilical vessels, arteritis in newly-born, .80; 
phlebitis in newly-born, 81 ; fistula, 112. 

Umbilicus, haemorrhage from, in newly-born. 
102; hernia, 113; inflammation of vessels in 
newly-born, 80 ; treatment of suppuration, 
85 ; tumours of, 111. 

Urachus, persistent, enuresis from, 644. 

Uraemia, acute, in scarlet fever, 901 ; in acute 
nephritis, 617 ; in chronic nephritis, 621. 

Ureter, dilatation of, 607 ; supernumerary, 610. 

Urethra, haemorrhage from, in newly-born, 104. 

Urethritis, 638 ; gonorrhoeal, 638. 

Uric acid, in anaemia, 798 ; in chorea, 677 ; in 
cyclic vomiting, 289; in malnutrition, 200; 
in early infancy, 595 ; infarctions, in kidney, 
610 ; causing haematuria, 104. 

Urine, acetone in (see Acetonuria), 603 ; ar- 
rest of secretion (see Anuria), 604 ; albumin 
in, 595; blood in (see Hematuria), 59S 
"brick dust" in, 601; composition of, 596 
daily quantity of, 594 ; diacetic acid in, 603 
examination of, 37 ; hyperacidity of, in rheu- 
matism, 1091 ; incontinence of, 644 ; with 
adenoids, 265 ; in diabetes, 1091 ; in myelitis, 
767 ; in vesical calculus, 650 ; indican in (see 
Indicanuria), 602 ; in infancy and child- 
hood, 594; methods of collecting, 37, 594; 
microscopical examination of, 595 ; physical 
characters of, 595 ; pus in (see Pyuria), 600 ; 
reaction of, 595 ; specific gravity of, 595 ; su- 
gar in, 596 (see also Glycosuria), 599; 
urea in, 596 ; uric acid in, 596 (see also Li- 
thuria), 601. 

Uro-genital organs, tuberculosis of, 1032. 

Uro-genital system, diseases of, 594. 



Urticaria, 874; following diphtheria antitoxine, 
991 ; in influenza, 1073 ; in intestinal indi- 
gestion, 367 ; papulosa, 874 ; scarlatiniform 
rash with, 905. 

Uvula, bifid, 239; diphtheria of, 958; elonga- 
tion of, 258; cause of asthma, 474; causing 
cough, 472 ; oedema of, 258 ; inflammation of, 
258. 

Vaccination, 931 ; choice of virus, 932 ; meth- 
ods of, 932 ; revaccination, 932. 

Vaccinia, 931 ; complications and sequelae, 935 ; 
variations in course of, 935. 

Vapourizer, 59. 

Vapour bath, 54. 

Varicella, 929 ; etiology, 929 ; symptoms, 929 ; 
complications, 930 ; diagnosis, 931 ; gangre- 
nosa, 872, 930 ; incubation, 929 ; quarantine, 
931 ; treatment, 931. 

Vegetables, allowed from third to sixth years, 
188; forbidden from third to sixth years, 
189. 

Vegetations on valves in endocarditis, 578. 

Vein, internal jugular, thrombosis of, 593 ; um- 
bilical, 558. 

Veins, abdominal, dilated in cirrhosis of liver, 
412; in thrombosis of vena cava, 593. 

Vena cava, thrombosis of, 593. 

Ventricles, cardiac, relative thickness of, 560. 

Vertigo, in cerebral abscess, 726 ; in cerebellar 
tumour, 732 ; in functional disorders of heart, 
590. 

Vesical, calculi, 650 ; spasm, 649. 

Viscera, abdominal, transposition of, 308 ; fre- 
quency of inflammations of, 39 ; haemorrhages 
of, in newly -born, 97. 

Voice, hoarse or husky, with adenoids, 264; 
nasal, in hypertrophy of tonsils, 272; with 
adenoids, 264 ; in diphtheritic paralysis, 791. 

Volvulus, foetal, cause of malformations, 307. 

Vomiting, 285; from overfilling the stomach, 
285 ; in acute gastric indigestion, 285 ; in 
acute intestinal obstruction, 285; in perito- 
nitis, 285 ; in nervous diseases, 285 ; at onset 
of acute infectious disease, 286 ; from toxic 
substances in the blood, 286; reflex, 286; 
from habit, 286 ; chronic, 286 ; of blood, in 
ulcer of stomach, 304 ; stercoraceous, in ap- 
pendicitis, 392; in intussusception, 382; cy- 
clic, 287 ; etiology, 288 ; diagnosis, 289 ; treat- 
ment, 289. 

Vulva, herpes of, 643. 

Vulvitis, gangrenous, 644. 

Vulvo- vaginitis, gonorrhoeal, 641 ; symptoms, 
641 ; diagnosis, 642 ; treatment, 643 ; simple, 
640 ; symptoms, 641 ; diagnosis, 642 ; treat- 
ment, 643. 



INDEX. 



1117 



Walking, causes which prevent, 25 ; delayed, in 
rickets, 228; late, in malnutrition, 198; when 
attempted, 25. 

Wasting, in tuberculosis, 1040 ; simple (see 
Marasmus), 204. 

Water, function of, in diet, 126. 

Weaning, 167 ; time for, 167 ; indications for, 
167 ; sudden, 168. 

Weather, hot, prophylaxis against diarrhoea in, 
325. 

Weight, 15 ; at birth, 16 ; curve during first 
few weeks, 16 ; curve of first year, 17 ; from 
second to fifth year, 19 ; of older children, 
19 ; from birth to sixteenth year, 20 ; best 
indication of nourishment, 163 ; loss of, in 
acute inanition, 195; stationary, indications 
in, 179 ; symptom of inadequate nursing, 163. 

Werlhof s disease (see Purpura), 810. 



Wet-nurse, in acute gastro-enteric infection, 
327 ; in acute inanition, 196 ; selection of, 
166 ; dangers of syphilis, 1067. 

Wet-nursing, 166 ; versus artificial feeding, 158 ; 
indications for, 158; disadvantages of, 159; 
moral question involved in, 159. 

Wheal, in urticaria, 874. 

Wheat jelly during second year, 186. 

Whey, 152. 

White-swelling of knee, 847. 

Whooping-cough (see Pertussis), 936. 

Winckel's disease, 90. 

Worms, intestinal, 395 ; tapeworm, 395 ; symp- 
toms, 397 ; treatment, 397 ; roundworm, 398 ; 
symptoms, 399 ; treatment, 399 ; thread- 
worms, 400 ; symptoms, 400 ; treatment, 401. 

Wrist, enlarged epiphyses in rickets, 227. 

W T ry-neck (see Torticollis), 683. 



THE END. 



THE PRINCIPLES AND PRACTICE 
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By WILLIAM OSLER, M. D., 

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